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Presidential Review Directive 5

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A National Obligation

Planning for Health Preparedness for and Readjustment of the Military,Veterans, and Their Families after Future Deployments


National Science and Technology Council

Presidential Review Directive 5

Executive Office of the President

Office of Science and Technology Policy

August 1998


About the National Science and Technology Council

President Clinton established the National Science and Technology Council(NSTC) by Executive Order on November 23, 1993, and he serves as Chairman.This Cabinet-level council is the principal means for the President tocoordinate science, space and technology policies across the Federal Government.The NSTC acts as a "virtual" agency for science and technology to coordinatethe diverse parts of the Federal research and development enterprise. Membershipconsists of the Vice President, Assistant to the President for Scienceand Technology, Cabinet Secretaries and Agency Heads with significant scienceand technology responsibilities, and other White House officials.

An important objective of the NSTC is the establishment of clear nationalgoals for Federal science and technology investments in areas ranging frominformation technologies and health research to improving transportationsystems and strengthening fundamental research. The Council prepares researchand development strategies that are coordinated across Federal agenciesto form an investment package that is aimed at accomplishing multiple nationalgoals.

To obtain additional information regarding the NSTC, contact the NSTCExecutive Secretariat at 202-456-6100.

About the Office of Science and Technology Policy

The Office of Science and Technology Policy (OSTP) was established bythe National Science and Technology Policy, Organization and PrioritiesAct of 1976. The OSTP's responsibilities include advising the Presidentin policy formulation and budget development on all questions in whichscience and technology are important elements; articulating the President'sscience and technology policies and programs; and fostering strong partnershipsamong Federal, State and local governments, and the scientific communitiesin industry and academe.

A National Obligation

Planning for Health Preparedness for and Readjustment of the Military,Veterans, and Their Families after Future Deployments


Improving the Healthof Our Military, Veterans, and Their Families


We have a national obligation to protect to the extent possible thehealth of our military, veterans, and their families. Those we place inharm's way to protect the national interest deserve the best. The 1991Gulf War highlighted both our successes and failures. Even though the numberof casualties, in the traditional sense, was low, Federal agencies responsiblefor the health of our troops were not prepared to deal with the healthissues that followed the War's completion.

Federal agencies discovered numeroushealth related deficiencies in monitoringthehealth of deployed troops. For example, our record keeping capabilitieswere not designed to track troop and asset movements to the degree neededto determine who might have been exposed to any given environmental orwartime health hazard. Seven years later, we just now have a complete accountingof who was actually deployed to the Gulf.

In addition, we discovered major deficiencies in the way we approachhealth risk communication. While the desire is strong to disseminate allrelevant health information to the affected groups as soon as possible,we must ensure that information is delivered in a way that is understandableand causes neither unwarranted concern norundue complacency. We must ensure that even during wartime situations,the military leadership ensures accurate communication of risks associatedwith countermeasures, such as vaccines, and maintenance of accurate records.

Our Nation's research programs also must bewell coordinated and designed to fill gaps in our knowledge that can beapplied to improving the health of our military, veterans, and their families.Here, coordination across Federal research agencies is required to ensurethat scarce research dollars are spent in a way that addresses the specialhealth needs associated with troop deployments.

The President is committed to heeding the lessons learned in the 1991Gulf War and subsequent deployments in Bosnia, Haiti, Rwanda, and Somalia.The plan detailed in this report reflects that commitment. This plan providesa blueprint for coordination among Federal agencies and proposes strategiesto correct deficiencies in our current state of military readiness andfor improving health care for our military, veterans, and their families.

Neal Lane

Assistant to the President


Science and Technology

Table of Contents


Improving the Health of Our Military, Veterans, andTheir Families iii

Executive Summary vii

Chapter 1: Introduction

Lessons Learned

Establishment of PRD/NSTC-5

Scope of the Plan

How the Plan Was Developed

Factors Influencing the PlanChapter 2: Deployment Health

Deployment Health Goals,Objectives and StrategiesChapter 3: Record Keeping Military Personnel InformationManagement

Military Personnel InformationManagement Goals, Objectives, and Strategies

Health Information Management

Health Information ManagementGoals, Objectives, and Strategies

ImplementationChapter 4: Research

Research Goals, Objectives,and Strategies

Setting Research PrioritiesChapter 5: Recommendations

Improving Coordination

Creation of a Military andVeterans Health Coordinating Board

Creation of an InformationManagement/Information Technology Task Force

Recommendations For SpecificAgency ActionsAppendix A: A Guide to HealthRisk Communications

Appendix B: PRD/NSTC-5 InteragencyWorking Group and Task Forces

Appendix C: Establishmentof NSTC/PRD-5

Appendix D: List of Abbreviations

Improvingthe Health of Our Military, Veterans, and Their Families


We have a national obligation to protect to the extent possible thehealth of our military, veterans, and their families. Those we place inharm's way to protect the national interest deserve the very best. The1991 Gulf War highlighted both our successes and failures. Even thoughthe number of casualties, in the traditional sense, was low, Federal agenciesresponsible for the health of our troops were not prepared to deal withthe health issues that followed the War's completion.

Federal agencies discovered numerous health related deficiencies associatedwith troop deployments. For example, our record keeping capabilities werenot designed to track troop and asset movements to the degree needed todetermine who might have been exposed to any given environmental or wartimehealth hazard. Seven years later, we just now have a complete accountingof who was actually deployed to the Gulf.

In addition, we discovered major deficiencies in the way we approachhealth risk communication. While the desire is strong to get all relevanthealth information out to the affected groups as soon as possible, we mustensure that information is delivered in a way that is understandable andcausesneitherunwarranted concern nor unduecomplacency. We must ensure that even during wartime situations, healthcare professionals accurately communicate risks associated with countermeasures,such as vaccines, and maintain accurate records.

Our Nation's research programs also bewell coordinated and designed to fill gaps in our knowledge that can beapplied to improving the health of our military, veterans, and their families.Here, coordination across Federal research agencies is required to ensurethat scarce research dollars are spent in a way that addresses the specialhealth needs associated with troop deployments.

The President is committed to heeding the lessons learned in the 1991Gulf War and subsequent deployments in Bosnia, Haiti, Rwanda, and Somalia.The plan detailed in this report reflects that commitment. This plan providesa blueprint for coordination among Federal agencies and proposes strategiesto correct deficiencies in our current state of military readiness andfor improving health care for our military, veterans, and their families.


Neal Lane

Assistant to the President


Science and Technology Policy



The Federal Government has an unwavering obligation to care for thoseplaced in harm's way to defend the vital interests of the Nation. Therefore,the Federal Government must be able to respond promptly and effectivelyto the health needs of our military, veterans, and their families. In particular,when health problems are identified following a military deployment, plansmust be in place to improve and facilitate cooperation and coordinationamong the Departments of Defense (DoD), Veterans Affairs (VA), and Healthand Human Services (DHHS), as well as among other appropriate agenciesof the Executive Branch. This report provides the first comprehensive setof recommendations designed to help ensure that this obligation is metin a manner that takes into consideration the successes and failures ofpast deployments.


Because of the subsequent health issues associated with veterans whoserved in the Gulf War, President Clinton established the PresidentialAdvisory Committee on Gulf War Veterans' Illnesses (PAC) on May 26, 1995.This Committee was to ensure an independent, open and comprehensive examinationof health concerns related to Gulf War service. The Committee issued itsFinal Report on December 31, 1996, which documented its review of the government'soutreach, medical care, research, efforts to protect against and to assessexposure to chemical and biologicalweapons warfare, and coordination activitiespertinent to Gulf War veterans' illnesses.

The Committee recommended that the National Science and Technology Council(NSTC) develop an interagency plan to address health preparedness for andreadjustment of veterans and families after future conflicts and peacekeepingmissions. Presidential Review Directive (PRD)/NSTC-5 responds to the Committee'srecommendation. In particular, PRD/NSTC-5 directs DoD, VA, and DHHS toreview policies and programs and develop a plan that may be implementedby the Federal government to better safeguard those individuals who risktheir lives to defend our Nation's interests. The plan was to focus onexisting policies and lessons learned from the Gulf War and other recentdeployments such as those in Bosnia, Haiti, and Somalia.

How the Plan Was Developed

An NSTC Interagency Working Group (IWG) was established to conduct thereview and planning process. Members of the IWG included representativesfrom DoD, VA, and DHHS. The IWG oversaw the work of four task forces thatfocused on (1) deployment health, (2) record keeping, (3) research, and(4) health risk communications. Each task force reviewed policies and programsthat relate to health preparedness of, and readjustment for, veterans andtheir families after future deployments. In particular, each task forceconsidered lessons learned from the Gulf War and other recent deploymentssuch as in Bosnia and Somalia. Each task force paid special attention toissues associated with chemical and biological weapons as well as the impactof emerging technologies and international cooperation.

Major Factors Influencing the Plan

During the review and planning process, the following major factors(other factors are identified in chapter 1) were identified that influencedthe plan's development and its potential for success:

  • Deployment can encompass a wide range of missions. Historically, most veterans'health and benefit issues related to service in combat operations. Now,U.S. forces are more likely to deploy into non-combat environments suchas peacekeeping, peacemaking, humanitarian assistance, or training.
  • There is a division of responsibilities between DoD and VA for the healthand health care of military service members and veterans of military service.The two Departments function under distinct titles of U.S. Code and distinctcongressional oversight. In addition, DHHS has responsibility in cooperationwith state and community governments for overall public health in the UnitedStates.
  • Veterans' response to present and future health and benefit issues andgovernmental actions may be tempered by a long history of military members'experiences with government and military leadership, and bytheirfrequent mistrust of and lack of confidence in government actions and motives.
  • The evolution of science, medicine, and societal perceptions regardinghealth and illness limits our ability to predict the future reality andexpectations regarding health, acceptable risks, disease prevention tools,and illness.
  • The current expectation is for far fewer casualties than in the past forthetypes of most missions we are likely to undertake.

Extensive review and analysis of Gulf War veterans' illnesses and riskfactors by government agencies, the Presidential Advisory Committee, andother groups have identified a number of opportunities for government actionaimed at minimizing or preventing future post-conflict health concerns.Actions to ameliorate, avoid, or, ideally, prevent such health effectsinclude: improving service members' understanding of health risk information;improving medical and non-medical countermeasures; enhancing governmentcollection of health and exposure data, along with improving linkages amonghealthinformation systems; coordinating agency research programs; and improvingdelivery of health care services to veterans and their families.

The Deployment Health Task Force (chapter 2) developed objectivesand strategies to support the following five goals: (1) maintain a healthy,fit, and physically- and mentally- ready military force; (2) identify andminimize or eliminate the short- and long-term adverse effects of militaryservice, especially service during deployments (including war), on thephysical and mental health of veterans; (3) preserve the health and well-beingof those who have served and their families; (4) strengthen the nationalstrategy to protect and defend military service members from warfare andterrorism with Cchemical and Bbiological Weaponswarfare(CBW)agents; and (5) implement an effective health risk communication strategy.The Task Force highlighted the importance of recent initiatives withinDoD to improve force health protection and medical surveillance especiallyduring deployments. In addition, the Task Force addressed the need forthe government to respond promptly and in a coordinated manner to boththe anticipated and unanticipated health needs and concerns of veteransreturning from major deployments through appropriate programs for theirevaluation, health care, and benefits/compensation determinations. To preparefor future health preparedness, DoD needs to critically evaluate currentforce health protection programs and exploit new and emerging technologiesto improve force health protection continually.

The Record Keeping Task Force (chapter 3) focused on informationmanagement (IM) and information technology (IT) issues in two broad areas:military personnel information and health information management. Improvementsare needed in both these areas to ensure the accuracy, timeliness, security,and retrievability of information that must be entered into records orautomated systems that document personnel or health history for activeduty, National Guard, and reserve service members and veterans. The TaskForce highlighted current initiatives of DoD and VA that support the objectivesand strategies necessary to meet these goals.

The Research Task Force (chapter 4) established six goals withsupporting objectives and strategies. The first goal is for the FederalGovernment to have the coordinated capability to apply epidemiologicalresearch to determine whether deployment-related exposures are associatedwith post-deployment health outcomes. The second goal is for the FederalGovernment to maintain a balanced research program targeted at: (1) improvedprevention, intervention, and treatment strategies for priority healthrisk factors and exposures and (2) improved biologically based dose-responsemodels. The third goal is for the Federal Government to have the capabilityto collect systematically population-based demographic and health datato enable longitudinal evaluation of the health of all service personnel(active duty, reservist, National Guard) throughout their military careersand after leaving military service. The fourth goal is for the FederalGovernment to develop the capability to collect and assess data associatedwith anticipated exposures during deployments. The fifth goal is for theFederal Government to establish the capability to monitor deployments forthe appearance of novel or unanticipated health risks and to deploy assetsquickly to collect and assess data relevantto newly identified threats. The sixth goal is for the Federal Governmentto maintain a wide range of national and international collaborative relationshipsto enhance research efforts.

The Health Risk Communications Task Force structured its reviewand its goals, objectives, and strategies into a guide for developing healthrisk communications for deploying, deployed, and returning military members,veterans, and their families (appendix A). The Task Force's planning guideoutlines the questions and actions necessary to: develop a health communicationplan and select a strategy; analyze and segment intended audiences; selectappropriate messages and channels; develop written communication objectives;develop a written implementation and monitoring plan; and assess the effectivenessof the plan.


The IWG identified the essential recommendations emanating from theinteragency plan (chapter 5). While each task force developed strategies,which in essence are recommendations for new or continuing actions in specificareas, key recommendations must be addressed in orderto meet the goals and objectives contained in this plan.

There must be ongoing coordination of all agencies involved in maintainingthe health of military members (active duty, National Guard, and reservist),veterans, and their families. Therefore, the IWG recommends creation ofa Military and Veterans Health Coordinating Board (MVHCB). Once established,the MVHCB would ensure coordination among VA,DoD, and DHHS on a broad range of health care and research issues relatingto past, present, and future military service in the U.S. Armed Forces.The MVHCB is modeled on the Persian Gulf Veterans Coordinating Board, whichis enhancing interagency coordination especiallyon research and clinical care related to health issues of Gulf War veterans.The MVHCB should be chaired by the Secretaries of the DoD, VA, and DHHS.Representation on the MVHCB and its workinggroups should include policy and program level staff from these Departments.As necessary, the MVHCB should call upon representatives from veterans'service organizations, other governmental agencies, and civilian institutionsfor expert advice and consultation. Note that the U.S. Coast Guard functionsas part of the U.S. Department of Transportation (DOT), except in timeof war, when it becomes a part of the U.S. Navy. DOT's advice will be importantin carrying out the recommendation included herein.

To succeed with many of the goals and objectives laid out in this planthe government requires ongoing direction and coordination for the Departments'health and personnel information management and record-keeping activities,especially activities associated with deployments. The IWG recommends thatDoD and VA, in consultation with DHHS, establish an ongoing interagencytask force to coordinate IM/IT efforts, including the development of standardsand other requirements.

In addition to the creation of these two coordinating groups (MVHCBand IM/IT Task Force), the IWG recommends the following actions:

  • DoD should complete implementation of recently issued directives on jointmedical surveillance and force health protection. DoD should proceed withits contract with the National Academy of Sciences (NAS) and the NationalResearch Council (NRC) for a 3-year program of scientific, technical, andpolicy analysis activities entitled "Strategies to Protect the Health ofDeployed U.S. Forces."
  • DoD and DHHS, Food and Drug Administration(FDA) should accelerate their efforts not only to identify regulatory issuesassociated with the use of investigational products during military exigencies,but also develop strategies to resolve them. Although relevant in somecases, use of investigational products by civilians, for example as countermeasuresfor domestic terrorism, is outside the scope of this activity.
  • DoD and VA, in consultation with DHHS, should establish, with appropriateconfidentiality safeguards, programs that:
  • Develop and maintain comprehensive electronic health and health risk factorinformation on all recruits and officer accessions at the time of initialmilitary training.
  • Collect and maintain military personnel data, including demographic andoccupational data, and longitudinal records of service member's militaryexperiences, including pertinent data on occupational and environmentalexposures and events.
  • Support transfer of pertinent data among DoD and VA health and compensationinformation systems.
  • VA, DoD, and DHHS should develop and implement a coordinated interagencyprogramto communicate health risk information related to current and future deployments,especially combat operations, to military members, veterans, family members,and the public.
  • DoD and VA shall maintain a robust, biomedical research, development, testing,and evaluation program emphasizing research priority areas identified inthis plan.
  • DoD shall ensure that military medical manpower requirements include scientiststrained in the medical specialties essential for force protection researchand program execution.


Chapter 1



The Nation has a commitment to protect and care for, to the maximumextent possible, the health of military personnel, veterans, and theirfamilies. The President has vowed "to improve the health of our veterans,their families, and all who serve our Nation, now and in the future." Thisresponsibility includes minimizing adverse health effects of military service—boththose experienced during the years of military service and those that firstappear years after the period of military service. The Federal Governmentneeds to demonstrate its commitment by making sure the practices and proceduresto meet this goal are in place and effectively used. In addition, our civilianand military leaders at every level of government and military servicesneed to keep in mind the importance of meeting this commitment.


The Nation and the government's response to the health problems andconcerns of veterans after their return from the Gulf War did not matchthe battlefield health protection successes of that war. The Departmentsof Defense (DoD) and Veterans Affairs (VA) did implement health and readjustmentprograms to address the expected post-war health problems of veterans.However, DoD and VA were not fully prepared to recognize, respond promptly,and treat the type of health problems reported by a large number of GulfWar veterans. The number of veterans wounded or injured in the line ofduty was small, but new challenges included:

  • The possibility of injury due to chemical and biological warfare agents;
  • Concerns over chronic diseases due to infectious and toxic exposures;
  • Unexplained post-deployment symptoms;
  • Concerns over illnesses with long latency periods following exposure;
  • Concerns over illnesses that might affect family members, close contactsand children conceived post-deployment; and
  • Higher rates of motor vehicle injury and death, and of other accidentalinjury, among war veterans.
The government's initial response was not part of a prevention and planningstrategy that could have been developed before deployment. In particular,the government's response was not well coordinated. As a result, Federalefforts did not fulfill the expectations of Gulf War veterans and theirfamilies.

The evolution of our Nation's commitment to the health and health protectionof military members parallels the evolution of our concepts of wartimestrategy. With superior advanced technology, military planning and operations,our wartime strategy over the past 50 years has evolvedandis continuing to evolve from reliance on strong logistical support andsuperior numbers of personnel and equipment to a strategy of light, mobile,highly capable forces. This strategy places fewer military members in harm'sway in the traditional sense, but those few will need to be more fit, healthier,more highly trained, and more mentally resilient.

The hazards during a deployment may be the physical threats of combat,environmental extremes, injury, or illness; the physical and psychologicalthreats of weapons of mass destruction; toxic environmental threats; orthe psychological threats associated with combat, peacekeeping, refugeecare, disaster relief, arduous conditions, or physical and social isolation.

The Gulf War also exposed many deficiencies in the ability to collect,maintain, and transfer accurate data describing the movement of troops,potential exposures to health risks, and medical incidents in theater.These problems were of two basic types: the lack of procedures and mechanismsto support the automated collection, maintenance, and transfer of usefulinformation; and lapses in the process of the collection of data by personneland health care managers in theater. Without accurate record keeping, ithas been extremely difficult to get a clear picture of what risk factorsmight be responsible for Gulf War illnesses. It also has been difficultto ensure that appropriate service-related benefits are allocated accuratelyto those who served.

Many of the major health concerns and uncertainties identified afterthe Gulf War are similar to those associated with other major foreign deployments.The response to these concerns could have been more effective if therewere a better understanding of the potentialbiological and toxicological associations between exposure and response.Better knowledge of biologically based relationships between specific exposuresand specific health outcomes enhances: (a) analysis of potential causesof illnesses; (b) research and development on effective prevention, intervention,and treatment strategies; and (c) development of an accurate and effectivehealth risk communication plan to inform troops about potential exposurerisks. Furthermore, if epidemiological researchers had comprehensive population-basedtroop health assessments and exposure monitoring data and data systems,they might have been better able to definepotential associations between exposures and outcomes. A coordinated researchprogram is required to ensure that, to the extent possible, this knowledgeis available for future troop deployments.

Our actions before, during, and after the Gulf War also made it apparentthat we must do a much better job of health risk communication. For example,service members must understand the risks associated with countermeasures,such as vaccines. DoD and VA must routinely develop well-reasoned healthrisk communication strategies when attempting to convey to large numbersof veterans the potential risk associated with hazardous exposures.

The President has committed the Nation to applying to future troop deploymentsthe lessons learned from the Gulf War and other recent military actions.He has directed DoD and VA to create a new force health protection program.He has stated that "Every soldier, sailor, airman, and marine will havea comprehensive, life-long medical record of all illnesses and injuriesthey suffer, the care and inoculations they receive, and their exposureto different hazards."


Because of the subsequent health issues associated with Gulf War veterans,President Clinton established the Presidential Advisory Committee, on GulfWar Veterans' Illnesses (PAC) on May 26, 1995.This Committee was to ensure an independent, open, and comprehensive examinationof health concerns related to Gulf War service. The Committee issued itsFinal Report on December 31, 1996, which documented its review of the government'soutreach, medical care, research, efforts to protect against and to assessexposure to chemical and biological weapons, and coordination activitiespertinent to Gulf War veterans' illnesses. During the course of the Committee'sdeliberations, government efforts to address and to resolve veterans' concernscontinued, consistent with respective agencies' missions.

Extensive public review and analysis of Gulf War veterans' illnessesand risk factors have identified a number of opportunities for governmentaction aimed at minimizing or preventing future post-conflict health concerns.Ameliorating, avoiding or, ideally, preventing such health effects canbe approached through a variety of means. These include improving servicemembers' understanding of health risk information; enhancing governmentcollection of health and exposure data; coordinating agency research programs;and improving the delivery of health care services to veterans and theirfamilies.

The Committee recommended that the National Science and Technology Council(NSTC) develop an interagency plan to address "health preparedness forand readjustment of veterans and families after future conflicts and peacekeepingmissions." Presidential Review Directive (PRD)/NSTC-5 responds to the Committee'srecommendation. In particular, PRD/NSTC-5 directs the DOD, VA, and DHHSto review policies and programs and develop a plan that may be implementedby the Federal Government to better safeguard those individuals who risktheir lives to defend our Nation's interests.


The plan will focus on existing policies and lessons learned from theGulf War and other recent deployments such as those in Bosnia, Haiti, Rwanda,and Somalia. Using the Committee's recommendations as a guide, the planaddresses the following areas:

  • Health (e.g., stress prevention, treatment, research; medical surveillanceadequacy, coordination; interventions for families).
  • Outreach and health risk communication.
  • Record keeping (e.g., accountability, timeliness, cross-agency coordination,application of new technologies).
  • Research (e.g., adequacy, quality, coordination, dissemination of results).
  • Biological and chemical weapons preparedness and research.
  • Application of emerging technologies (e.g., telemedicine, technology transfer).
  • International cooperation and coordination, especially on research andtechnology matters.

An NSTC Interagency Working Group (IWG) was established to oversee thereview and planning process. Members of the IWG included representativesfrom DoD, VA, and DHHS. Specific components of the plan were delegatedto the following four task forces:

  • Deployment Health: addressing health issues associated with troop deployment(pre- to post-deployment), including surveillance, monitoring, prevention,and clinical services.
  • Record Keeping: addressing issues associated with record keeping, includingactive duty/veteran health records and other types of records that arecrucial to understanding the health risks associated with hazardous environmentaland occupational exposures.
  • Research: identifying research priorities and identifying gaps in thecurrentportfolio of federally funded research. Special attention was given toresearch needs associated with protection fromchemicaland biological warfare (CBW) agents.
  • Health Risk Communications: incorporating lessons learned and perspectivesfrom agencies such as the Agency for Toxic Substances and Disease Registry(ATSDR), National Institute for Occupational Safety and Health (NIOSH),and Environmental Protection Agency (EPA), along with those of DoD andVA.
Each task force was asked to review policies and programs that relate tohealth preparedness of and readjustment for veterans and their familiesafter future deployments. In particular, each task force was toconsiderlessons learned from the Gulf War and other recent deployments such asin Bosnia and Somalia. Each task force was instructed to pay special attentionto CBW issues as well as to the impact of emerging technologies and internationalcooperation.


A significant factor influencing this plan is the inherent diversityassociated with modern troop "deployments." Numerous military deploymentsoccur each year. An individual may deploy many times during a militarycareer. The total career deployment history for an individual is referredto as his or her deployment lifecycle. The number of military members ina specific deployment may be less than ten, several thousand, or hundredsof thousands. A deployment may last for a few days or forsix 6 months orlonger. Military members may deploy to a well-supported U.S. or foreignmilitary base in a developed country, may be on a ship making foreign portvisits, or may deploy to a field setting in an urban or rural part of adeveloping country. The deployment missions vary. They include: militaryliaison and training support, joint and coalition force exercises, constructionprojects, humanitarian assistance (including healthcare), refuge relief,peacekeeping, peacemaking, low intensity conflict, and war, or any combinationof these and other missions. Within the United States, military members"deploy" to fight forest fires, provide disaster relief, assist againstterrorist actions, maintain civil order, or support drug interdiction andborder patrol operations.

Another major influence on this plan is the division of responsibilitiesfor the health and health care of military service members and veteransof military service inherent in the DoD and VA. The two Departments functionunder distinct Titles of United States Code and with oversight by differentcongressional committees. The two Departments must respond to their ownlegislative, regulatory and administrative mandates and restrictions inareas of eligibility for care, benefits and compensation, different missions,and budget realities. In addition, DHHS is responsible (in coordinationwith the States) for overall public health in the United States, managesan extensive biomedical research portfolio including diseases of militarysignificance, maintains surveillance and registries applicable to militarymedicine, and has broad regulatory responsibilities [e.g., Food and DrugAdministration (FDA)]Food and Drug Administration() FDA that affect the military.

The long history of military members' experiences with government andmilitary leadership, and the not infrequent mistrust of government actionsand motives, tempers any response to present and future health and benefitissues for veterans. A mandate for the government to be responsible andaccountable for actions and exposures that affect the short- and long-termhealth of military members and veterans requires the government to knowtheir health status at entry into service and over the continuum of theirmilitary service and remaining life span. Real and perceived uses of theextensive data that need to be collected will lead to valid questions regardingthe confidentiality of health data and the bioethical safeguards on theuse of such data. In addition, efforts to protect, preserve, or enhancethe health of military members may be viewed with suspicion if such measuresappear to restrict retention in the military, infringe on freedom of choice,limit personal or career opportunities, pose a potential adverse healtheffect, or exceed current civilian norms regarding risk and benefit.

The evolution of science, medicine, and societal perceptions regardinghealth and illness limits our ability to predict the future reality andexpectations regarding health, acceptable risks, disease prevention tools,and illness. Thus, even guided by past and present experiences, our visionof the future is limited regarding the potential health effects of militaryservice in the next century and the tools that we will requiretomitigate those health effects. Therefore, this plan must be dynamic andflexible to address unforeseen challenges and capitalize on important developments.

Finally, the plan must acknowledge the current, national expectationthat, compared to military deployments during the first half of this century,most modern deployments are expected to carry much less risk to the healthand well-being of those who deploy and their families. The concern withplacing or keeping U.S. forces in harm's way is not limited to going intocombat and sustaining combat casualties. The current expectation influencesapproaches and decisions regarding military training, use or non-use ofprotective countermeasures, environmental hazards during deployment, psychologicalstresses of deployment and service, terrorist threats, and other issues.The military and civilian leadership of the government is being held tothe extremely high standard of avoiding adverse health effects subsequentto military service—service that by definition, tradition, and realityis inherently hazardous.

Other important factors include:

  • Budget Constraints. Budgetary constraints are a concern for any major developmenteffort. Several of the initiatives identified in this plan have been delayedbecause funding for them was not programmed. Rapidly evolving technologicaladvances can also have an impact on budgetary considerations, as can congressionalactions or new legislative requirements.
  • Congressional Actions. Congressional actions, especially those that changeentitlements, must be addressed. Sometimes, these actions can delay otherchanges as available resources are redirected. New legislative mandatescan also have an impact on current or future program requirements in thearea of revised or more stringent procedures that can delay program milestonesand subsequent systems development.
  • Security Issues. The development of the databases that are required tosupport the information requirements must be carefully monitored to ensurethat sensitive data are protected. The sensitive data may relate to eithernational or personnel security.
  • Increasing Personnel and Operations Tempo. The current tempo of operationsand increased deployment of personnel increases the potential exposureto health risks. Personnel are more likely to be participating in manydifferent operations in varying geographic locations during their career.
  • Increased Development of Chemical and Biological Weapons (CBW) agents byOther Countries. As more and more countries continue to develop CBW agents,the need to document both preventive and intervention therapies is moreimportant.
  • Compliance with Procedures and Mechanisms. There is still the potentialfor lapses in the established processes in areas such as data collectionand health risk communication by personnel and health care managers militaryleadership and their medical support in theater. Such potential lapsesmust be addressed through training and monitoring.
  • Health Care Received Outside the Military Health System (MHS). Care isoften rendered outside the MHS by civilian health care providers for someactive duty members, their families, and retirees, and for Reserve andNational Guard members. Unless beneficiaries receiving care from civiliansmake their personal health information available to DoD or VA, governmentrecord keeping will be incomplete.


Chapter 2



The Nation and the military long have recognized the obligation to minimizethe hazards of wartime military service and to provide both acute and chroniccare for those injured or disabled during wartime service. Weapon systemsand protective measures are continuously improved to allow U.S. militarymen and women to achieve their military objectives with the least riskto their survival and their survival as a military force. Threats fromchemical and biological warfare agents present special problems and requirethe Nation to greatly improve its detection and protective measures. Immediatemedical and surgical capability, rapid medical evacuation, and an extensivesystem of military medical centers provide for care on the battlefieldand care, treatment, and rehabilitation upon return home. VA medical centersprovide care for those requiring extensive rehabilitation and chronic carefollowing separation from military service.

Force health protection before and during the Gulf War was implementedin varying degrees. Although U.S. forces experienced historically low ratesof classic preventable diseases and combat casualties, force health protectionefforts were incomplete, were neither standardized nor centralized amongdeployed forces, were not well documented, and, for the most part, didnot anticipate the need for follow-up post-deployment. While field commandersmade a concerted effort to ensure their forces were protected from medicalhazards, there was not a sufficiently strong, centralized program requiringspecific protection against known threats or to ensure specific force healthprotection actions. Implementation of countermeasures often was localizedand, at times, not adequate, consistent, or systematic. Similarly, medicalsurveillance when conducted at the local level was incomplete and not alwayswell documented; therefore, centralized analysis of exposures and healthconsequences was extremely difficult during and after the war.

Lessons learned from the Gulf War resulted in a complete review of doctrine,policy, oversight, and operational practices for medical surveillance andforce health protection. Major lessons were applied in subsequent operationsand improvements in force health protection were realized during subsequentdeployments. For example:

  • In Haiti, disease threats were identified pre-deployment and preventionguidance was provided to commanders at deployment. Force health protectioninitiatives were implemented locally, but there were limited efforts toensure use of appropriate countermeasures, conduct medical surveillance,and analyze the effectiveness of the programs and initiatives.
  • Commanders in Somalia employed personal protection and countermeasuresbased on pre-deployment threat assessments. Medical surveillance was bettercoordinated and more effective. Medical personnel used the deployed militarypublic health laboratory to isolate the cause of diarrheal disease amongMarines and to recommend effective countermeasures. Medics and commanderstook preventive actions to control mosquitoes and rodents before exposuresoccurred. Analysis of health events during and after this operation ledto definite improvements in force health protection for future operations.
  • Preventive medicine officers deployed as part of the first teams into Rwandain support of this United Nations operation involving 300-400 U.S. militarymembers. The U.S. European Command had specific force health protectionrequirements in operational guidance and established surveillance for diseasesand health risks. Military members received specific health risk informationduring pre- and post-deployment activities.
  • The operation in Bosnia had a formal, theater-wide health surveillanceand force health program including: (1) systematic risk assessments ; (2)useof of appropriate countermeasures; (3) comprehensive medical surveillance,including ongoing medical, environmental, laboratory, and operational hazardmonitoring; and (4) analysis of procedures for further improvements.
Health protection is receiving increasingly higher attention from fieldcommanders, as shown by improving operational-level infectious diseaseprophylaxis, environmental sanitation, and disease surveillance. However,more remains to be done.

Until recently, DoD leadership had not fully integrated post-deploymenthealth issues (other than rehabilitation of injuries) into military operationalplanning. Indeed, the military has not been sufficiently sensitive to militarymembers' health concerns and generally has responded slowly to post-deploymenthealth problems. Now, the Office of the Secretary of Defense (OSD), theJoint Chiefs of Staff, and the military services, in consultation withthe VA, are aggressively pursuing unified force health protection strategiesto protect military members from health hazards associated with militaryservice. The civilian and military leadership together is actively involvedin this dynamic process. There is clear recognition of the importance ofprotecting military members in every operation. For the first time allgovernment departments with a role in assuring military members' healthare actively collaborating to assure that preventable post-deployment healthconcerns are addressed throughout military service and after separation.


Goal 1. Maintain a healthy, fit, andphysically and mentally ready military force.

Objective 1.1. Direct military doctrine and policies for maintaininga healthy, fit, and ready force that reflect the lessons learned from preparationsfor recent major deployments.

Strategy 1.1.1. Complete integration of the force health protectionstrategy into the doctrine and policy of the Office of the Secretary ofDefenseOSD, the Joint Chiefs of Staff, and the military services.

Strategy 1.1.2. Insert force health protection values, policy,rationale, and guidance into the curriculum of all leadership trainingfrom non-commissioned officers through the seniormilitary and civilian leadership of DoD.

Strategy 1.1.3. Strengthen health and fitness programs to maintainphysical and mental health throughout a military career.
 Objective 1.2. Assure that the force health protection strategyaddresses the needs of special military populations, including reservecomponents, women, and minorities.

Strategy 1.2.1. Develop a plan to address the unmet militaryhealth readiness and training requirements of reserve component personnel.Supporting Narrative

The desired outcome is a healthy and fit force that is physically andmentally ready to succeed in fulfilling the military mission. This overarchingstrategy relies on the military services' action to ensure the health andfitness of their service members, successful application of all capabilitiesof DoD's Military Health System (MHS), and coordination of DoD activitieswith the VA and DHHS. During peacetime or in training, the MHS providescomprehensive health services throughout DoD that equal or exceed civilianstandards of care. DoD, through the military services and the MHS, targetsthe health and fitness and the optimal physical and emotional well-beingof military members and their family members.

The involvement of military leaders in all aspects and levels of forcehealth protection is critical. Ultimately, the fitness, readiness, andwell-being of the military force are an operational commander's responsibility.Line leadership, direction, and support will be critical to assuring thehighest degree of health and health readiness of the deploying force commensuratewith achieving operational objectives.

Goal 2. Identify and minimize or eliminateshort- and long-term adverse effects of military service, especially serviceduring deployments (including war), on the physical and mental health ofveterans.

Objective 2.1. Direct doctrine and policies that reflect lessonslearned from the Gulf War and subsequent major deployments to protect thehealth of the military force during future deployments.

Strategy 2.1.1. Complete integration of the force health protectionstrategy into the doctrine and policy of DoD, the Joint Chiefs of Staff,and the military services. [Same as 1.1.1]

Strategy 2.1.2. Develop improved protective measures, doctrine,and policies to address special problems of medical defense against chemicaland biological warfare agents.

Strategy 2.1.3. Insert force health protection values, policy,rationale, and guidance into the curriculum of all leadership trainingfrom non-commissioned officers through the DoD senior military and civilianleadership. [Same as 1.1.2]

Strategy 2.1.4. Develop a force health protection strategy thataddresses the prevention and health care requirements arising from theeffects of combat and deployment-related stress on the military memberand his/her family.

Strategy 2.1.5. Conduct an assessment of DoD resources, includingappropriately trained and qualified personnel that are required to successfullyaccomplishing the force health protection strategy.
 Objective 2.2. Maintain military medical readiness that encompassesthe ability to mobilize, deploy, and sustain the most capable field medicalservices and support for any operation requiring military services andto maintain and project the continuum of healthcare resources requiredto provide for the health of the force.

Strategy 2.2.1. Provide mission-capable medical units and militaryhealth care providers uniquely trained, equipped, and qualified to meetthe health needs of military forces for any mission within the operationalspectrum.

Strategy 2.2.2. Take advantage of research and technology toadvance the health care support to deployed forces to ensure that deployedmilitary members who become casualties due to battle or nonbattle injuriesor illness receive optimal health care to preserve life, function, andhealth.

Strategy 2.2.3. Provide a seamless and fully integrated medicalevacuation system to support military operations with trained and readyresources capable of supporting the continuum of care.

Strategy 2.2.4. Develop a standardized, integrated and seamlesssystem of medical command and control for the military medical communitywithin the Global Command and Control System (GCCS)/Global Combat SupportSystem (GCSS), including development and deployment of an individuallycarried data device (see chapter 3).
 Objective 2.3. Use external expert review, analysis, and recommendationsfor improvement of policies, procedures, and science and technology effortsto protect the military force in future deployments.

Strategy 2.3.1. Proceed with a DoD contract with the NationalAcademy of Sciences (NAS) and the National Research Council (NRC)for a 3-year program of scientific, technical, and policy analysis activities.Objective 2.4. Ensure all Federal Government programs support andcomplement goals to minimize or eliminate short- and long-term adverseeffects of military service. Strategy 2.4.1. Strengthen relationships among DoD, VA, DHHS,and other Executive Branch agencies to make optimum use of all Federalhealth, science, and technology expertise that can contribute to forcehealth protection during deployments and to health problems that may occurpost-deployment.

Strategy 2.4.2. Resolve policy and regulatory issues to improvethe ability to plan for and provide optimal health protection strategiesfor military forces.Supporting Narrative

In November 1997, President Clinton directed "the Departments of Defenseand Veterans Affairs to create a new Force Health Protection Program."The desired outcome is a military force fully protected from preventableand avoidable health threats throughout military operations and deployments.The four critical elements of the Force Health Protection Strategy, froman operational perspective, are: as follows:

  • Threat analysis. Identifying operational, disease, environmental, biological/chemicalor other medical hazards or stress risks to deployed forces before andduring a deployment.
  • Countermeasures. Using appropriate strategies (during training, as a partof long- range health readiness preparations, and immediately before andduring deployments) to mitigate these risks: personal protection; drugsand vaccines; chemical and biological detection, protection, and decontamination;deployment stress reduction and critical incident debriefings; and otherhealth service systems.
  • Medical surveillance in the area of operations. During the operation, monitoringthe health status of the force and the health threats to determine short-and long-term risks to health and to take appropriate countermeasures.
  • Analysis. Conducting current, prospective, and retrospective analyses todetermine outcomes and trends in health status and health threats, andto assess the need for or the effectiveness of changes in policy, doctrine,or operational practices.
The DoD recently published a directive and instruction on joint medicalsurveillance (DoD Directive 6490.2, Joint Medical Surveillance, August30, 1997, and DoD Instruction 6490.3, Implementation and Application ofJoint Medical Surveillance for Deployments, August 7, 1997), which directthe implementation of some aspects of this strategy. The Director, JointStaff authored a memorandum to all theaters and services directing theinclusion of health surveillance into all deliberate and crisis actionplanning. The revision of Joint Publication 4.02, Doctrine for Joint HealthService Support, will incorporate force health protection and joint healthservices concepts into joint doctrine. Force health protection responsibilitieshave been incorporated into Joint Publication 5.00-2, Joint Task ForcePlanning Guidance and Procedures. Insertion of force health protectionlanguage into the Joint Strategic Capabilities Plan (Chairman, Joint Chiefsof Staff Instruction 3110.03, Enclosure E) is underway. Theater operationalplans are being reviewed to ensure appropriate force health protectionplanning is incorporated into deliberate and crisis action operationalplans.

The involvement of military leaders in all aspects and levels of forcehealth protection is critical. Ultimately, the protection and well-beingof the military force is a commander's responsibility. In future deployments,line leadership, direction, and support will be critical to assuring thehighest degree of health protection for the deployed force. The degreeof involvement of senior civilian and military leadership within the Officeof the Secretary of Defense OSD and the Joint Staff in the developmentof doctrine and policy has been unprecedented. The force health protectionstrategy ensures commanders and leaders at every level have a force thatis protected through any operation, and supported with exceptional physicaland mental health care capability. Service members deserve every measureof protection as they serve in the military. Leaders' commitment and chargemust be to ensure the protection of military members today, tomorrow, andinto the next century.

DHHS (FDA) and DoD need to explore viable options to allow access toproducts that may protect military members during military exigencies.As part of DHHS (FDA) and DoD's exploration of viable options, both Departmentsmay also consider whether there is a limited need to modify certain existingvaccine and drug requirements for military personnel under differing exigencies.Information on those requirements must be included in the training of militarypersonnel who may, for their protection, be required to use or be offeredvaccines and drugs that have not been approved for marketing for the intendeduse.

The prevention and amelioration of the adverse effects of combat anddeployment-related stress help to preserve military strength. The emotionalhealth of the service member, although invisible, affects all aspects ofhis/her behavior. In theater, stress that adversely affects emotional healthmay affect the ability to maintain physical health and hygiene, may hinderthe ability to physically complete a mission, or may affect the good judgementand creativity needed to find and apply solutions to accomplish the missionon the rapidly moving, high-tech battlefield. Long-term adverse effectsof combat and deployment-related stress may include poor physical and mentalhealth, dysfunctional family and work relationships, substance abuse, andpoor military and civilian work performance.

Goal 3. Preserve the health and well-beingof those who have served and their families.

Objective 3.1. Improve and coordinate interagency efforts toprovide for the health care needs of military service members, includingreserve component personnel , and their families following return fromdeployments.

Strategy 3.1.1. Develop interagency solutions to provide accessto the appropriate levels of financial support, health services, and readjustmentcounseling for military service members transitionto future military service or civilian life.

Strategy 3.1.2. Establish a combined DoD, VA, and DHHS plan torespond promptly and in a coordinated manner to both the anticipated andunanticipated health needs and concerns of veterans returning from majordeployments.
 Objective 3.2. Ensure DoD and VA have appropriate programs and resources,including appropriately trained and qualified personnel, for the evaluationand health care of veterans with health concerns of particular interestafter major deployments.

Strategy 3.2.1. Conduct a combined DoD and VA assessment ofthe adequacy of the Departments' evaluation and health care programs forveterans regarding:
  • Post-war illnesses, including diagnosed and unexplained symptomatic illnesses
  • Diseases with long latent periods following exposure
  • Diseases affecting family members and close contacts
  • Reproductive health outcomes
Strategy 3.2.2. Conduct a combined DoD and VA assessment ofthe adequacy of the Departments' evaluation and health care programs forveterans and their dependents with stress-related and mental health concerns.

Strategy 3.2.3. Prepare a combined DoD, VA, and DHHS plan fora standardized post-deployment registry program including standard registrycriteria, standard registry evaluation protocol, and standard registry/registryevaluation database.

Strategy 3.2.4. Prepare DoD and VA plans for providing individualand family counseling and mental health services for military members andmembers of their families, especially in preparation for and upon the returnhome of the deployed military member.
 Objective 3.3. Assure that special military populations, includingreserve components, women, and minorities, benefit from programs for thepost-deployment health care of veterans.

Strategy 3.3.1. Develop a plan to address the unmet healthcare requirements of reserve component personnel upon return from deployments.

Strategy 3.3.2. Conduct a combined DoD and VA assessment of theadequacy of the Departments' programs for the post-deployment health careof veterans to address the needs of women and minorities.Supporting Narrative

Support for the family of a military member before, during, and aftera deployment requires additional attention, especially for prolonged deploymentsor deployments into a combat theater and for reserve component members.Deployment may create problems within a family unit or may exacerbate existingproblems. Deployment may strain already fragile family relationships andcoping mechanisms. The heightened personal and interpersonal stress uponall family members due to the sudden changes—first from separation andsecond, and far more significant, from the military member's return—canhave adverse effects on the physical and mental health of each family member.The stresses also may have adverse effects on interpersonal relationshipswithin the family unit. Spousal abuse and child abuse—physical, emotional,and sexual—frequently result from heightened family stress due to deploymentand return home.

Local commanders need the support and tools for preventing or dealingwith the destructive outcomes from these tenuous family situations. Thefamily stress and the lack of the personal and family skills to respondproductively to that stress often result in a less effective military member.Adverse outcomes may include marital discord, substance abuse, divorce,discipline problems, and arrest and conviction for abuse. Family problemsreadily become mission-related issues if they detract from a military member'sability to perform his/her duties or take the command leaders' attentionaway from performing their mission. Professional resources need to be availableto respond to military families in crisis—before, during, and after deployment—andalsoto provide the family and marriage counseling needed to prevent the crises.Both DoD and VA need contingency plans to respond to the increased needsof military families before, during, and after deployments. The preventionof adverse effects on the family of military deployments can minimize associatedlong-term adverse effects on the military member's physical and mentalhealth, performance, and career, and on the family members' physical andmental health.

Goal 4. Strengthen the national strategyto protect and defend military service members from warfare and terrorismwith chemical, biological, radiological, andchemical agents.

Objective 4.1. Assure strong national commitment to improvingmilitary defense and response capability against CBW agents.

Strategy 4.1.1. Complete the Presidential Report on preparationsfor a national response to medical emergencies arising from terrorist useof weapons of mass destruction (Public Law 105-114, Sec. 210).

Strategy 4.1.2. Establish an interagency program for medicaldefense against CBWand biological agents to address the military'sreadiness and response capability for war and terrorist use of CBW agentsagainst military populations.
 Objective 4.2. Use external, expert review, analysis, and recommendationsfor improvements in the military's policies, procedures, and science andtechnology efforts to detect, protect, and defend against biological andchemical warfare and terrorism agents.

Strategy 4.2.1. DoD proceeds with its contract with NAS andNRC for a 3-year program of scientific, technical, and policy analysisactivities. [Same as 2.2.1]Supporting Narrative

The Gulf War emphasized the threat of biological and chemical warfareon the battlefield and the effect of its use, or threat of use, on theconduct of war and its aftermath. While there is continued concern aboutour ability to protect and defend our military forces from terrorism associatedwith CBR warfare CBW agents, DoD does haveunique capabilities and requirements for the protection of military membersfrom CBWwarfare agents, whether used on the battlefield or as terroristweapons. Part of the NAS and NRC task is to assess current techniques fordetecting and tracking exposures of military members to harmful agents,including chemical and biological warfare CBW agents, and make recommendationsfor improvements in technologies and policies. The NAS will evaluate currentpolicies, doctrine, and training, and recommend adjustments to strategiesto afford better protection against such agents. The effort includes afocus on technologies, tools and methods for improved detection and monitoring,;physical protection and decontaminations,; and vaccines and other prophylacticagents.

Goal 5. Establish an effective health risk communication programthat educates and informs active military personnel, veterans, and theirfamilies throughout the deployment lifecycle and beyond on issues relatedto health risks and available services.

Objective 5.1. Coordinate health risk communications effortsof the DoD and VA.

Strategy 5.1.1. VA and DoD, in consultation with DHHS, willdevelop and implement an interagency health risk and health research communicationprogram based on the guide for health risk communication contained in appendixA of the this interagency plan.

Strategy 5.1.2. VA and DoD, in consultation with DHHS, will developand implement an interagency applied research program on health risk communicationfor military members, veterans, and their families.Objective 5.2. Improve outreach and training capability to stateand local health professionals who provide services to active duty military,veterans, and their families.

Strategy 5.2.1. DHHS, VA, and DoD will build essential capacityfor electronic communications with state and community public health departmentsto enhance the dissemination of health risk information to veterans andtheir families through local public health infrastructures.

Strategy 5.2.2. DHHS, VA, and DoD will provide training to localpublic health officials on the use of essential information technologiesto disseminate and receive health risk information from veterans and theirfamilies.Supporting Narrative

Health risk communicators (public affairs officers, line commanders,researchers, medical professionals, community involvement specialists,and others) must often work closely with their intended audience concerninghealth risk issues and the consequences of hazardous exposures. Unfortunately,communicators frequently rush to provide information before they have definitiveinformation about the health risk or hazard.

What are the planning problems faced by do these communicators face?Effective health risk communicators must initially determine what exposuredata are available, consider what scientific uncertainty is evident fromthe data, and understand what is being done to provide appropriate medicalcare. Then, they must determine how to convey the problematic conceptsto an intended audience that expects accurate and complete answers. Additionally,they must understand the meaning of thehealth risk associated with thehazardous exposure. Finally, communicators must understand their limitsand get helpon with scientific issues that require more technical expertise.Once these communication aspects have been developed,Then, the communicatormust translateall the scientific information into an easily understandablemessage. To meet these objectives, health risk communication professionalsfacingthese situations must develop an overall health communication strategicplan.

Whether derived from research findings or not,tThe way risk estimatesare conveyed to the intended audience significantly affects how individualsperceive those risks. Single-value estimates do notprovide an indicationof indicate the degree of uncertainty of risks associated with the exposureestimate. On the other hand, communicating a range of risk estimatesdoesnot often convey seldom conveys the conservative nature of some risk estimates.For example, most individuals maynot be aware be unaware that risk estimatesare typically created by extrapolating from information based on high doseexposures to the very low dose that an individual might actually encounter.

"Risk" is a complex concept and "hHealth rRisk cCommunication" oftenappears complicated and unstructured. A large and growing body of literatureconfirms the common intuition that humans factor much more into perceptionsof risk than the "objective" findings of well- designed research studies.For example, is the risk voluntary or involuntary? If Does an individualor group that imposes a risk on others,does it listen attentively to theconcerns of the risk bearer, or turn a deaf ear?

An additional layer of such fFactors, those associated with risk controllability,may be particularly salient within the context of "risk perception." Oftentoo many elements pertain to a risk's relative significance for any singlehealth communication process to yield a single correct approach. Nonetheless,a strategic planning process can yield more effective communication outcomesby fosterfostering sustained dialogue between different factions of thescientific community and between scientists and the intended audience.

The health risk communicator must realize that an audience's reactionto a message about a hazard ismuch more complexthan just considering thehazard itself. Many personal variables contribute to risk perception andhow an individual will respond to the risk,. including: Such variablesinclude education, values, cultural background, religion, social experience,health, economic status, psychological outlook, and trust level. Thesefactors will also influence the level of trust and mutual respect betweenthe communicator and the audience. Therefore, when developing communicationmessages, the health risk communicator needs to know the intended audiencein great depth, including its attitudes, concerns, channels, and the consequencesof specific risk factors. To be successful, the health risk communicatormust develop an approach in which determine how to achieve effective two-waycommunication, constructive discussion, and resolution of health risk issuescan be achieved.

Chapter 3




ALlack of data on personnel deployments and movements in theater makesit difficult to accurately monitor deployment-related health risks or conductresearch on populations at risk. Further, data currently collected areoften difficult to access and are stored in multiple locations. As a result:

  • Commanders in Chief in theaters of operations may not have accurate ortimely data on personnel assets (numbers, characteristics, and locations)needed to assess operational capabilities;.
  • Research analysts and joint managers may not be able to make necessaryassessments and comparisons across military services and their respectivecomponents (active, reserve, and guard);.
  • Linkages between the personnel and pay functions differ among the servicesresulting that result in multiple data entry, complex system maintenance,and pay problems that have an impact on service members and their families..
  • Reservists who are mobilized are often "lost" in the system (both automatedand administrative) and are not effectively tracked or accounted for asthey transfer from active to reserve status; and.
  • Personnel (active, reserve, and civilian) are not consistently trackedor accounted for in and around the theater.
  • Personnel (active, reserve, and civilian) are not consistently trackedor accounted for in and around the theater.
It wasNot untilfive 5 years after the end of the Gulf War before were databases were corrected to the point that there is 99 per cent accuracy inidentifying those who had been deployed. There are no reliable databasesthat describe or track specific locations of individuals while they arein theater. One result is that service members and medical researchershave difficulty documenting potential exposures to environmental and otherhazards of the theater.

Military personnel functions and information systems support and sustainactive duty and reserve service members, and their families, throughouttheir military careers. This includes periods of peacetime, during mobilizationand war, and beyond military service as members separate or retire andtransition back into civilian life. Many interactions and transfers ofdata with other agencies must be supported, especially with the VA. TheMilitary Personnel Information Management Strategic Plan supports the entiremilitary personnel life cycle with primary emphasis on the deficiencieshighlighted during and after the Gulf War. This discussion focuses on theparts of the plan that relate directly to those deficiencies and on ourobjective to develop a system to provide a seamless process of life-cyclesupport to the service member integrated with transparent delivery of benefitsand entitlements to the veteran.


Goal 1. Ensure the accuracy, timeliness,security, and retrievability of information that must be entered into recordsor automated systems that document personnel history for active, guard,and reserve service members and veterans.

Objective 1.1. Resolve the record keeping deficiencies that continuetohave an impact on affect readiness, contingency and peacekeeping operationsas well as those that have an impact on affect the quality of service weprovide to service members and veterans to ensure that they receive correctpay, accurate credit for service, and appropriate benefits and entitlements.

Strategy 1.1.1. Design and implement an automated system tocollect and maintain the required information to meet the operational needsof military Commanders in Chief; military personnel and manpower managementneeds; and the needs for historical documentation, scientific researchand analysis, and health surveillance and monitoring. Once the informationrequirements are known and defined, mechanisms must be put in place tocollect and maintain the data in formats that facilitate their use.

Strategy 1.1.2. Define information requirements and develop standarddata that can be implemented across all military services and components.This strategy will result in definition of a complete set of data that,when collected, would satisfy the requirements of the personnel, medical,and research communities throughout the Federal gGovernment.

Strategy 1.1.3. Develop mechanisms to facilitate access to existingdata that are currently used or are historical in nature. Historical datathat are already archived, are being used, or will be collected over thenext few years, will not benefit from the new data collection and maintenancesystem. Although these data are not adequate in terms of the full requirements,in many cases it is the only information available for this period andfor many service members and veterans.Supporting Narrative

Strategy 1.1.1

Current deficienciesare a direct resultof from the inability of theexisting systems (over 1770 separate systems with multiple, complex interfaces)to support collection and maintenance of the required information, especiallyin the areas of personnel accountability and asset visibility. These deficienciescontinue to affect our readiness, contingency, and peacekeeping operations.They continue toimpact affect our ability to assess potential health hazardsand the quality of service we provide to service members to ensure thatthey receive correct pay, accurate credit for service, and appropriatebenefits and compensation. The Defense Integrated Military Human ResourcesSystem (DIMHRS) will be designed to resolve the information collectionand access deficiencies identified. DIMHRS will enable the Department DoDto collect and maintain the standard military personnel data and will addressthe problem of asset visibility. It will enhance our ability to accountfor reservists who are mobilized and change to active duty status. It willassure that they receive proper credit for service, timely pay, and benefitsand entitlements for themselves and family members. It will also give DoDthe capability to track military and civilian personnel in and around thetheater of operations, support the collection of casualty and medical evacuationinformation that will be integrated with medical management systems, andprovide data for use by outside agencies such as the VA and the Red Cross.DIMHRS will correct the personnel, pay, and operational records keepingissues that were made obvious during the Gulf War. It will be a single,fully integrated, all-service, all-component, military personnel and paymanagement system. DIMHRS will be a major link in a process that will provideseamless delivery of personnel services and veterans' benefits and entitlements.Since much of the required data must be collected in the field and transmittedto central databases, DIMHRS must encompass both the field level data collectioncapability and the central databases for all services. It will use modern,web-based technology and be built on a COTS commercial off-the-shelf platform.

Funding for initiation of DIMHRS was obtained in FY1998 and an initialoperating capability is planned for 2003. Detailed requirements are beingdefined with full coordination and support from all service components,the Joint Staff, and other communities who may need information from thepersonnel data (for instance, the medical community). The DIMHRS requirementsdefinition team will also participate in the Health Affairs business processreengineering project to define requirements for tracking the use of investigationaldrugs and to ensure that the personnel system will incorporate their requirements.

After the initial investment establishing DIMHRS, significant savingsare expected as maintenance and development costs for specified legacysystemswill be are eliminated and military personnel management processeswillbe are streamlined and improved. The project isa complexone in that itrequiresthe coordination and support from all of the services as well asfrom OSD. Senior management must ensure that action officers throughoutthe Department understand the importance of the program and the inadequaciesof current practices.

One of the most significant problems in managing military personnelin theater and through mobilization is that the different services, andtheir components (Aactive, Rreserve, and Gguard), collect data that areinconsistent and incomplete. During the period fFrom 1992 through 1995,the DoD personnel community focused on the definition of informationrequirements, development of the Defense Personnel Data Model (DPDM), anddefinition of standard personnel data elements to address the informationrequirements. These data will beimplemented acquired through the DIMHRS.

Strategy 1.1.2

A series of focused workshopswere was held to identify information requirementsfor effective military personnel management, including tracking personnelin theater and maintaining adequate personnel records for future accessto ensure appropriate benefits, documentation of potential exposures, andaccurate credit for service. The workshops included full participationfrom all military components (active, reserve and guard), OSD staff analystsand managers (from Reserve Affairs, Health Affairs, and other parts ofOSD), Joint Staff representatives, and, for areas of special interest,representatives fromVeterans Affairs VA and other Federal Aagencies. Datadefined by the workshops were incorporated into the DPDM.

As a parallel effort, all data collected by the services military personnelsystems (active, reserve and guard) were analyzed and also incorporatedinto the DPDM. A set of standard data elements was defined and coordinatedthroughout the personnel community, with other DoD communities and withother agencies. Standard data elements will replace the approximately 30,000component- and system-specific elements identified in our systematic reviewof personnel systems. The Defense Personnel Data Model (DPDM) is completeand maintained through the regular data administration program. Over 1,500standard personnel data elements have been developed.

Strategy 1.1.3

Even after DIMHRS is fully implemented, there will be a need to accessdata and information collected, and archivedprior to before the systembecomingbecamebecomes operational. DIMHRS is expected to be available in 2003.Full integration and connectivity with other Federal agencies in orderto deliver support and services based on online or real-time access toDoD databases and systems will not be feasible until well after that date.As DoD and VA work toward providing transparent delivery of services, support,benefits and entitlements to service members and veterans, we will needto implement interim procedures and take incremental steps toward the abovementioned interagency systems integration and connectivity. Since datacollected and maintained in older legacy systems, and in other technologicalformats (paper, micro-fiche and optical storage) must be kept for at least75 years, an interim capability to facilitate access to these other sourcesof information is critical.

Several studies have identified business process improvements withinDoD, VA, and the National Archives and Records Administration (NARA) thatwill facilitate access to current and historical personnel information.Business Process Reengineering initiatives that will facilitate accessto existing data are briefly described below.

  • Transfer of Medical Records to VA. One of the earliest issuestackled by a joint DoD/VA task force, in 1992, was the failure to transferexpeditiously medical records to the VA for Gulf War (and other) veteransfiling compensation claims. After review of the processes then in place,the task force recommended that the Health Treatment Records be transferredto VA upon separation from active duty. This expedites the availabilityof needed medical information to the VA for Rreserve members returningfrom active duty deployment and for those regular active duty members separatingor retiring. While access to the existing medical records does not improvethe content of the records, it goes a long wayin toward accelerating theprocess that veterans must go through to obtain the benefits they haveearned.
  • Integrated Imaging Systems. In order tTo provide further interim actionsto facilitate electronic exchange of information between DoD and otherFederal agencies needing data extracts, or copies of personnel recordsand information, DoD is pursuing a Defense Personnel Records Imaging System(DPRIS) using optical imaging technology. DPRIS seeks to achieve interoperabilityamong the existing service optical imaged personnel file management systems.Adjuncts to this initiative include extending electronic query capabilityto other government agencies authorized to access military personnel records,and retiring optically imaged personnel records to NARA.
  • Retirement and Retrieval of Clinical Records. In 1995, DoD and NARA initiatedthe DoD/NARA Medical Records Retirement and Retrieval Project that recommendedan automated system be put in place that would use an electronic recordindex for retiring clinical treatment records for military members andtheir families. Under the current system, medical treatment record retrievalis costly,not timely slow, and sometimes does not occur. The proposed systemwill correct these inefficiencies and increases the probability that servicemembers and their families will be able to retrieve records of clinicaltreatment in military medical facilities during periods of mobilization,active duty, and deployment. This system will ease post-deployment transitionsfor family members of activated reservists as they move back into civilianlifeout of the military environment.
  • Joint Disability Evaluation Tracking System (JDETS). In the years followingthe Gulf War, a significant effort has been expended throughout DoD hastried to discernthe effects of how service in the Gulfupon affected thehealth of service members. Analysis of the services' Ddata on Gulf Warveterans discharged with disabilitieswas attempted to assist in determiningpotential were analyzed to determine possible causes of any ill effectsand to ensure equitable compensation of members affected. There were manydeficiencies in the services' ability to retrieve disability data withoutconstructing new databases for each new query. The lack of common dataacross the services, combined with differences in the tracking capabilitiesof the services, impeded the analyses and reporting capabilities of theDepartment. A business process reengineering study resulted in the definitionof requirements for a consolidated tracking system, the JDETS. JDETS introducedthe capability to tag members by specified criteria and track or analyzesubgroups of specific, defined data. Future planned interfaces with theDefense Integrated Military Human Resources System (DIMHRS) will resultin additional benefits both in further improve data quality and in processingtime for personnel in the disability evaluation system.
  • Joint Personnel Asset Visibility (JPAV). Personnel asset visibility isthe visibility of individual, unit, and location data that describe allpersonnel resources available to accomplish a Joint Task Force mission.JPAV will provide a database in theater that will contain information neededby the Commanders in Chief (CINC) to support operations and to identifylocations of individuals. JPAis dependentV depends on the military personnelsystems to obtain core data. During deployed operations, the United Statestransports massive amounts of materials, supplies, and personnel usingall available means of conveyance. JPAV will collect data from a varietyof systems and display that information to the user in a prescribed format.A JPAV prototype was deployed to Thailand for Exercise COBRA GOLD 96 inMay 1996. Future interfaces with DIMHRS will allow full realization ofthe potential benefit from JPAV.
  • Defense Casualty Information Processing System (DCIPS). During the GulfWar several problems in the casualty affairs and mortuary affairs arenasurfaced. Congressional hearings on some of these problems were held early1992, and a 1993 DoD Inspector General Report documents other deficienciesincluding the lack of common automated support for the management of casualtyand mortuary affairs information and lack of casualty tracking information.Each service has its own casualty affairs and mortuary affairs officesand information systems to support its own requirements. The services allconduct business in basically the same way under current DoD guidance.The Department has undertaken development of the Defense Casualty InformationProcessing System (DCIPS) tobetter manage better the automated informationprocesses that support the casualty/mortuary environment. Future interfacewith DIMHRS will ensure that DCIPS will have a full set of common informationfrom all services.

In 1994, the Defense Medical Information Management and InformationTechnology Program was established. It specifically addresses both themanagement of health information and the supporting technology. The goalof the program is to provide the right health information to the rightpeople at the right time across theentire continuum of health care operations.To this end, the MHS Information Management and Information TechnologyStrategic Plan, which is updated annually, addresses health informationrequirements including those necessary to resolve issues that arose duringand after the Gulf War. The specific issues the plan addresses include:

  • Accurate and Accessible Health Records. Current health records do not adequatelycapture all care rendered (including classified information). Health recordskept in the MHS are a combination of manual and automated data, which iscontained in multiple health records (inpatient, outpatient, mental health,and dental). Ideally, the provider manually enters the required medicalinformation directly into the appropriate health record. However, whenthe record is not available at the time care is rendered, the informationis collected on the appropriate form and sent to the records room to befiled later. Computer-generated information is available either electronicallyor in printed copy that is then filed in the health record. Paper-basedmedical records may be filed inappropriatelyand therefore (that rendersthem temporarily inaccessible), lost, or damaged. Paper-based records aredifficult to maintain and do not allow for a seamless exchange of patientinformationwhen needed.
  • Tracking of Patients. During the Gulf War, information regarding the admissionand diagnosis of patients at the deployed medical units in the theaterof operations was not timely or complete. In addition, patients could notbe adequately tracked within the medical evacuation process or at fieldfacilities.
  • Deployment of Medical Personnel with Necessary Deployment Skills. Identificationof fully qualified medical personnel for deployment to the Gulf or to supportingactivities in Europe and the United States was hampered by insufficient,inaccessible, or inadequate data. In addition, necessary interfaces betweenhealth and personnel systems either did not exist or were not robust enoughfor adequate transfer of data.
  • Capture and Transfer of Information Needed by the Office of the AssistantSecretary of Defense for Health Affairs [OASD (HA)], other DoD, or FederalAagencies. Existing health processes or systems do not capture adequatelyinformation needed by other organizations such as the Under Secretary ofDefense (Personnel and Readiness) [USD (P&R)] VA, or FDA. Health informationis needed by these other agencies to determine disability and VA healthcare entitlements and to meet FDA reporting requirements for investigationalnew drugs. In addition, information contained in systems managed by theseagencies is not always available to support health care delivery.

Goal 2. Ensure the accuracy, timeliness,security, and retrievability of information that must be entered into recordsor automated systems that document health history for active, guard, andreserve service members and veterans.

Objective 2.1. Resolve deficiencies in health record keepingthat have an impact on the health of our forces which in turn affects ourreadiness posture, contingency activities, and operations other than waras well as those that have an impact on the quality of both preventivecare and treatment for injury and illness provided to service members.

Strategy 2.1.1. Define, acquire, and implement a fully integratedCcomputer-based Ppatient Rrecord available across the entire spectrum ofhealth care delivery over the lifetime of the patient.

Strategy 2.1.2. Develop a total patient tracking mechanism tocapture information from the time the patient enters the medical systemas an inpatient until discharged from inpatient status, to include in-transitvisibility.

Strategy 2.1.3. Develop a mechanism to capture information ontraining and currency of skills for medical personnel.

Strategy 2.1.4. Define the requirements and develop the necessarymechanisms to transfer health information to non-medical or non-DoD departmentsand agencies.Supporting Narrative

Strategy 2.1.1

The MHS requires a single, integrated system that collects health dataand makes it available worldwide. A Ccomputer-based Ppatient Rrecord willcapture comprehensive, relevant, and accurate health information duringeach beneficiary's lifetime. It will provide the MHS with the ability tosupply clinical data to predict and evaluate health outcomes and to viewclinically relevant data where and when needed within a single, transportablecomputer-based patient record. An electronic patient record provides thecapability makes it possible to combine several enterprise-wide electronicmedical records concerning patient. A computer-based patient record generallymeets five criteria:

  • Developsing a system for identifying all health information, wherever itis provided.
  • Makesing information from multiple providers in various locations a partof the electronic record.
  • Developsing standardized terminology, data sets, and structure.
  • Createsing a consensus on security systems that protect the privacy ofhealth information.
  • Usesing data and knowledge bases to enhance services between geographicareas.
The following initiatives are underway to develop the Ccomputer-based PpatientRrecord:
  • Composite Health Care System (CHCS). This is a system currently supportsingelectronic capture of laboratory, radiology, pharmacy, patient scheduling,and patient administration (e.g., admissions, internal military treatmentfacility medical records tracking). The next upgrade of CHCS generationof this system, CHCS II will also include the Mmedical Rrecords Ddispositionand Aarchiving function. This is a tracking mechanism is essential forcollection of information on the handling and storage of health recordsas they move from medical to personnel (responsible for records dispositionand storage) and on to the VA (responsible for storage and archiving ofrecords). The next generation of this system, CHCS II, The CHCS II willsupport the comprehensive computer-based patient record. CHCS II will addnew areas of electronic data capture to include the operating room, anesthesia,mental health, ambulatory care documentation, vision, pharmacy, and consulttracking, and utilization management. The computer-based patient recordwill be built as a patient receives care (in theater or in a fixed militarytreatment facility). It will facilitate the electronic documentation ofthe delivery of care, and preventive services, increase interoperabilitywith other computer systems, and facilitate the exchange of data amongthe many players whether in the theater of operations, at the sustainingbase, at other locations, or with other fFederal agencies.
  • The Personal Information Carrier (PIC). Considering the mobile nature ofmany personnel during deployments, how can health information necessaryfor treatment be made available to health providers? One promising technologycurrently being developed is the Personal Information Carrier (PIC). ThePIC is a small, rugged, tag-like device intended to store an individual'smedical status and history, to include pertinent medical documents, radiographs,and vaccination records. The PIC can be carried by service members andupdated by medical personnel using portable computers at the time careis rendered. The PIC would be one piece of a computer-based medical recordsystem. The information on the PIC could be transmitted to central databasesas aredundancy safeguard in case of loss or damage to the card.
  • Preventive Health Care System (PHCS). This system will include immunizationtracking (important for readiness), preventive health, and health enrollmentrisk appraisal information. This system will support the "Put PreventionInto Practice" initiative (implementing the national Healthy People 2000program), and automate the Health Enrollment Appraisal Review (HEAR) questionnairecurrently used for health risk assessment. It will also integrate medicalhistory data contained in CHCS II. Medical personnel will use this systemto document and track immunization status, assess beneficiary health status,develop an individualized plan for preventive care, and track the stepsin the delivery of these preventive services as well as the outcomes.
Strategy 2.1.2

A seamless process and mechanismthat that includes in-transit visibilityand can track personnel from the time they enter the medical system untilthey are returned to duty, placed in a medical holding unit, medicallyretired, or die on active duty, including in-transit visibility, is essentialto managing casualties. The following two initiatives address this need:

  • Patient Administration Real-time Reporting and Tracking System (PARRTS).PARRTS will allow military leaders to obtain accurate computerized updateson hospitalized personnel involved in military operations. It providestimely patient information, a fuller accountability of patients under treatmentin the theater, and an ability to pass that information to leaders andto casualty notification officers on a near real-time basis. The informationincludes the number of beds in use in the theater, the number of admissions,total number of patients, battle casualties, non-battle injuries, diseases,evacuations, and deaths. This information is essential for identifyingcapability, early recognition of health trends, and location of patients.The surveillance data can be used to monitor medical threats and plan forappropriate defenses. It also allows medical commanders to reshape themedical force (quantity, mix, and location) based on current, accurateinformation,. It also and provides a database for planning future operations.This legacy system is operational and has supported Operation Joint Endeavorin Bosnia.
  • Patient In-Transit Visibility. The Transportation Command Regulating andCommand and Control and Evacuation System (TRAC2ES) will bethe automated decision support system, within a global network, that assistsin the command and control of patient movement. The system will facilitatethe assignment of lift (movement), beds, and en route patient care management.This will enable effective depiction of the impact of patients on transportationand other supporting activities and systems, allow for visibility of patientsas they move throughout the system, and alert receiving activities of patientand follow on support requirements. TRAC2ES will be availablefor joint, combined, and component operations in peace, operations otherthan war, and war. In the interim u Until this program is operational,the Defense Medical Regulating Information System and the Automated PatientEvacuation System each provide part of this functionality.
Strategy 2.1.3

Medical leaders need to be able to make informed decisions regardingwhich medical personnel are qualified for deployment in support of militaryoperations and what positions they should fill. This information allowsmedical commanders to select the right individuals to achieve the necessaryquantity and mix of medical personnel at each deployed location. This Theyneed current and accurate information must be current and accurate andshould includingde the status of general readiness training, medical skills,specialty skills, and the training required for assignment to a particulartype of field facility. The following initiative is currently underway:

  • Centralized Credentials Quality Assurance System (CCQAS). CCQAS will supportsmedical readiness by facilitatinge the identification of providers andselection of medical personnel with the requisite skills to support militaryoperations. At the military treatment facility, this database collects,tracks, and reports demographics, the provider's credentials information,specialty details, professional and additional training, license information,board certification, affiliations, and malpractice insurance. CCQAS supportsmedical readiness by capturing the above information for review duringselection of medical personnel for deployment. This information is enhancedwith five data fields: date of initial medical readiness training, currentunit identification code (UIC) for deployment, date of the UIC verification,date of commander verification of sustained medical readiness training,and mobilization practice specialty. This information is transmitted quarterlyby the military treatment facility each quarter and aggregated by the services.The next upgrade, CCQAS 2.0, will add risk management data (malpracticeclaims and adverse actions). Planning is also underway to include privileginginformation in future upgrades of CCQAS.
Strategy 2.1.4

Information must flow smoothly among DoD activities, the various departments,and agencies who have a need to access to health information. In addition,medical personnel need information related to treatment within the VA healthsystem, exposure to potentially harmful materials, and personnel information(such as location, duty history, and demographics). Exchange of informationis facilitated by standardized data definitions, standardized technology,and mechanisms designed to bridge systems with differing data or technologystandards. The following initiatives address this need:

  • Technology Standardization and Insertion. OASD (HA) works closely withthe Iinformation Mmanagement community to develop and implement commontechnical standards to achieve interoperability between DoD automationsystems. Efforts are also underway to export these emerging standards tothe VAeterans Administration for their adoption. The proliferation of amultitude of unique vendor approaches in hardware and software has createda technical architecture where many existing systems cannot pass or sharedata. The Defense Information Systems Agency, with participation from theMHS, is guiding the overall DoD standardization effort through the developmentof a Joint Technical Architecture and Common Operating Environment. ThisAarchitectural Fframework and associated policies haves been expanded toaddress unique healthcare requirements. These standards enhance the abilityto share data and also allow for software reuse, simplify system administration,and provide a consistent user interface throughout the MHS.
  • Data Standardization. OASD (HA) currently is staffing a proposal for developingdata standards for Llaboratory, Ppharmacy and Rradiology files. Data sharedwithin an enterprise must be standardized to eliminate the cost of delays,miscommunication, inconsistency, and incomplete information, as well ascosts associated with redundancy of data storage and duplication of datacapture. Standardization of data across an enterprise is essential if theenterprise is to achieve the goals of sharable, consistent, reliable datathat is accessible through interoperable automated systems. The standardizationof data is essential for enterprise-wide programs such as the CompositeHealth Care System CHCS II, the Personal Information Carrier, and clinicaloutcome performance metrics, to facilitate the transfer of data betweendepartments and agencies and reduce the amount of retraining required tooperate for new computer applications.
  • Information Exchange within DoD. The Composite Health Care System CHCSII will support data exchange such as tracking patient movement and locationof medical information and health records with other DoD departments. TheDefense Enrollment Eligibility Reporting System (DEERS), an Under Secretaryof Defense USD (Personnel and Readiness)(P&R) system, will providebasic demographic information to the Composite Health Care System II. DEERSwill be the repository for the central Master Patient Index (MPI), whichlocates clinically relevant data automated data stored in CHCS II at militarymedical treatment facilities. DEERS will also receive information fromthe health system (e.g., blood type, immunization status) needed by DoDprograms and commanders in support of military operations.
  • DoD/VA Data Sharing. DoD and VA systems are not compatible for direct transferof information. Modification of either system is not feasible. The DoDand VA are focused on sharing data through the use of open systems standards,rather than the adoption of a single automated system. On a monthly basis,information from the Comprehensive Clinical Evaluation Program (DoD's registryand evaluation program for Gulf War veterans) is available to the VA viathe World-Wide Web and File Transfer Protocolsthus providing convenientretrieval. The Ccomputer-based Ppatient Rrecord will also facilitate transferof data to the VA and other Federal agencies when appropriate. Effortsare underway to identify data exchange requirements and create additionalinterface mechanisms that will act as bridges between existing systems.
  • Information Exchange with the FDA. Investigational new drugs may be criticallynecessary during a deploymentin order to provide potential protection todeploying personnel or treatment for deployed personnel. Following a deployment,it may be necessary to determine if the uses of the drugs are a contributingfactor in illnesses among this group. Further, FDA's regulations for investigationalnewdrugsregulations require the collection of data concerning safety and efficacyof the product. Therefore, the capture of data related to these drugs isessential. A business process reengineering effort will be evaluated asa solution to address issues related to the use of investigational newdrugs in support of deployments. Such an effort would consist of inputfrom DoD, VA, FDA, and other agencies as appropriate. The record-keepingportion of this endeavor must support data requirements identified by theHealth Issues portion of this Task Force. Data requirementswill need tobe identified, processes established to capture the necessary data, fundingobtained, and possibly technology acquired to support the program. Thisproposal to implement a business process reengineering effort will be exploredwith the Health Issues Group of this Task Force and with the organizationsmentioned above.

Personnel Information Management

The Under Secretary of Defense (USD) Personnel and Readiness (P&R)Information Management Program involves the entire Mmilitary Ppersonnelcommunity. The Joint Requirements and Integration Office manages and implementsthe IM program and ensures that each initiative meets the Department'sgoalsand is effectively coordinated and implemented. Every initiative receivesfour or five levels of review: first, the project-specific working group,with appropriate representation from the services, Joint Staff, USD (P&R),and, where appropriate, other Federal agencies; second, internal P&Rstaff; third, the Joint Integration Group (JIG); fourth, where available,existing functional-area-specific steering committees (for instance, theJoint Casualty Advisory Board and the Military Personnel and Pay ManagementSystem Steering Committee); and fifth, the Military Personnel Policy ReviewCommittee (PRC).

The JIG provides high-level review and coordination on all productsand recommendations. It is a group of senior military personnel and payrepresentatives from all components, the Joint Staff, OASD (Reserve Affairs),and USD (P&R). Members are briefed regularly and kept informed of projectstatus and plans. Recommendations from the JIG are incorporated into boththe selection and performance of projects.

The PRC, chaired by the Deputy Under Secretary (Program Integration),is a Deputy Assistant Secretary level group that includes the Service PersonnelChiefs, the Director of Personnel (J1) from the Joint Staff, and representativesfrom OSD and the Service Secretariats. The PRC provides final review andcoordination. After comments are received from the PRC members, recommendationsand decision packages are forwarded to the USD (P&R).

Additionally, the Joint Requirements and Integration Office maintainsclose work ties to works closely with other Federal agencies and carriesout interagency business process reengineering programs through the DoD/VAReinvention Partnership Agreement signnged by the Secretaries of Defenseand Veterans Affairs in June 1994.

Health Information Management

A consolidated MHS Information Management and Information TechnologyProgram, which addresses health care requirements across the operationalspectrum, is thekey cornerstone to establishing a health information baseline,meeting future requirements, and addressing issues discussed in this plan.In addition, the service member life-cycle depicts the need for informationat differentpoints in times during the career of the service member. AnIt is importantfactor to successfully capturing the necessary informationis to identifying a single point of data entry for the collection of necessaryinformation.

The OASD (HA) has an established a management and oversight structurethat provides senior executive oversight of the MHS Information Managementand Information Technology Program and ensures that MHS investment in informationsystems and technologyare is firmly based on the goals and objectives ofthe MHS. The TRICARE Readiness Committee and the TRICARE Executive Committeedevelop broad policy guidance. The MHS Information Management ProponentCommittee and the Information Management Program Review Board oversee executionand ensure integration at the enterprise level. Functional Proponent WorkingGroups ensure the functional requirements are defined and prioritized tosupport customer needs and the policies set forth by the TRICARE ReadinessCommittee and the TRICARE Executive Committee.

The Theater Functional Steering Committee oversees the integration andapproval of health requirements in support of joint and combined militaryoperations. This committee aggregates and prioritizes medical requirementsfor all echelons of care and addresses functional areas including commandand control, medical logistics, blood management, patient regulation andevacuation, medical threat/intelligence, health care delivery, manpower/training,and medical capabilities assessment and sustainability analysis. Requirementsapproved by the Theater Functional Steering Committee are managed throughthe Theater Medical Information Program which integrates the capabilitiesinto medical deployment packages for use in land-based, non-fixed medicalfacilities, and aboard ship.

OASD (HA) has clustered information management and technology activitiesinto six discrete business areas: Cclinical, Eexecutive Iinformation/DdecisionSsupport, Rresources, Llogistics, Ttheater, and Iinfrastructure. Each ofthese business areas has prescribed responsibilities, expected outcomes,support requirements identified by the Theater Functional Steering Committee,and is managed by an Executive Agent.

Health information systems developed in the future will consist of standards-basedcommercial off-the-shelf, government -off-the-shelf, or MHS-developed functionalapplications, in that order of preference. Functional applications willbe supported by a DoD standard computing and communications infrastructureto facilitate the seamless flow of patient information across the operationalcontinuum.

The MHS is actively engaged in business process reengineering activitiesthat cover the spectrum of from continuous improvement at the militarytreatment facility level to radical changes in the delivery and managementof health care services for the entire enterprise. These activities focuson improving the processes associated with providing health care in peacetime,wartime and operations other than war.

In support of health information exchange for health care delivery tomilitary members (active, retired, and separated) who are entitled to carein the VA health system, an DoD/VA Executive Council DoD/VA meets on amonthly basis to address health care issues.

Chapter 4



Many of the major health concerns and uncertainties identified afterthe Gulf War are similar to those associated with other major foreign deployments.The response to these concerns could have been more effective had therebeen a better understanding of the potential biological and toxicologicalassociations between exposure and response. Better knowledge of biologically-based relationships between specific exposures and specific health outcomesenhances: (a) analysis of potential causes of illnesses; (b) research anddevelopment on effective prevention, intervention, and treatment strategies;and (c) development of an accurate and effective health risk communicationplan to inform troops about potential exposure risks. Furthermore, if epidemiologicalresearchers had comprehensive population-based troop health assessmentsand exposure monitoring data and data systems, they might have been betterable to define potential associations between exposures and outcomes.

Attention to the uncertainties of exposure-related health outcomes duringdeployment could have resulted in directed (or focused) research efforts,the results of which could have been applied before and during these deploymentsto mitigateagainst adverse health outcomes.

Furthermore, population-based health assessments of troops before andafter deployments could have improved the ability to answer readily thedeployment-related health concerns of veterans. Such knowledge could havealso helped to plan for future deployments. Although design, development,and implementation of databases are not research per se, they play an importantpart in the research process because the quality of these activities canhave a significant impact on the ability of epidemiological researchersto answer important questions about deployment health. Consequently, thisstrategic plan also describes database requirements necessary to enablethe pursuit of research.

The concerns of many veterans from other wars regarding their deploymentexperiences and their potential connection to long-term health problemsunderscore the need for a government focus on deployment health. Employmentof effective, evidence-based actions to mitigate deployment-related healthproblems in the past is enhanced by research aimed at identifying and understandingthese problems. It is for this reason that research is an essential componentof the overall deployment health strategy presented in this document.

The brief duration of the Gulf War and the relatively low incidenceof traumatic injuries focused attention on combat-related illnesses. Suchillnesses include the potential health consequences of exposures from thewartime environment. New health issues associated with chemical, biological,and radiological threats also emerged. These emergent health issues havebrought to the government's attention a requirement to enhance capabilitiesof addressing deployment-related health problems. The following have beenidentified as essential needs as the foundation for this research planThis research plan is designed to achieve following essential needs:

  • Epidemiological research capability and capacity to investigate exposure-outcomerelationships;
  • Focused research on deployment-related risk factors;
  • Epidemiological research-driven data and data system requirements for healthoutcomes and exposures (anticipated or novel).
The fFederal gGovernment's investment in health research spans multipleagencies and is the primary source of health research funding in the UnitedStates. Responsibility for execution of this plan will reside within theappropriate operational and research infrastructures in different agencies.Coordination, however, will be at an interagency level. Based on missions,capabilities, and capacities, the three primary agencies that will bearthe responsibilityof for implementing this strategy are theDepartmentsof Defense DoD,Veterans Affairs VA, andHealth and Human Services DHHS.


Goal 1. The U.S. gGovernment will havethe capability to apply epidemiological research to determine whether deployment-relatedexposures are associated with post-deployment health outcomes.

Objective 1.1. Maintenance of the capability and capacity toconduct epidemiological health studies (morbidity and mortality) as follow-upto military deployments.

Strategy 1.1.1. Establish guidelines for initiating morbidityand mortality follow-up studies.

Strategy 1.1.2. Establish guidelines for initiating necessarycoordinating efforts for deployment-related health follow-up activities.
 Objective 1.2. Maintenance of the capability to identify and linkexposure and health data by social security number (SSN) and unit identificationcode (UIC).

Strategy 1.2.1. Identify the responsible government agencycharged with collecting, consolidating, maintaining, and updating healthdata and related exposure data for all service members.

Strategy 1.2.2. Establish an interagency team charged with identifyingand selecting appropriate epidemiological study cohorts for deploymenthealth studies.Supporting Narrative

For the government to successfully acquire appropriate health and exposuredata using well designed data collection, archiving, and management systems,itneeds to have the capability to must be able to apply sound scientificprinciples to determine whether exposure-outcome relationships exist inconnection with a deployment.

Different departments, DoD and VA in particular, have epidemiologicalcapability and capacity that is spread across many sectors within thosedepartments. Essential to the establishment of the capability t To carryout exposure-outcome assessment, is the identification of the departmentsmust identify a locus for that activity.

Goal 2. The U.S. Government will havebalanced research programs targeted at (1) improved prevention, intervention,and treatment strategies for priority health risk factors and exposures,and (2) improved biologically based dose-response models.

Because some deployment-related health risk factors are already thesubjects of substantial targeted research efforts within the fFederal gGovernment,it would not be prudent to include them in this strategy. Consequently,this plan identifies a number of research priority areas that currentlydeserve special emphasis. These research areas are as follows:

  1. Chemical, biological, and radiological warfare (CBR) agents.
  2. Stressors.
  3. Emerging health concerns.
  4. Infectious diseases.
  5. Occupational risk factors and non-combat injuries.
Research Priority Area 1. Chemical, Biological,and Radiological (CBR) Warfare Agents

Objective 2.1. A broad knowledge base of the possible healtheffects of low-level exposures to CBR agents.

Strategy 2.1.1. Develop a separate strategic approach to researchon the health effects of low-level exposures to CBR warfare agents, environmental/chemicalagents, and other factors, alone or in combination.Objective 2.1. Improved protection measures for service members. Strategy 2.1.1. Develop improved masks with minimal burdento wearer while providing enhanced respiratory protection.

Strategy 2.1.2. Develop improved protective clothing examiningnew materials and technologies, that allow greater flexibility and longersustainment of activities before fatigue sets in.

Strategy 2.1.3. Develop pharmacological and other countermeasuresfor long-term effects of CBR weapons.
 Objective 2.3. Improved chemical, biological, and radiological detectiondevices.

Strategy 2.3.1. Define medically relevant detection requirementsfor CBR agents for operational forces.

Strategy 2.3.2. Develop wide area, standoff technologies to detectliquids, aerosols, and vapors, permitting a true-mapping information capability.

Strategy 2.3.3. Develop technologies to detectmedically and characterizerelevant levels of chemical and biological agents in water.
 Objective 2.4. Effective training methods for CBR personnel defense.

Strategy 2.4.1. Review current detection strategy and sensoremployment.

Strategy 2.4.2. Evaluate effectiveness of CBR agent training.

Strategy 2.4.3. Develop high-resolution (0-3 meters) chemical/biologicalagent dispersion modeling that supports transport and diffusion in complexterrain and build-up areas.

Strategy 2.4.4. Evaluate the effects of stress on leadershipand decision making in nuclear/biological/chemical warfare environments.
 Research Priority Area 2. Stressors

Objective 2.5. Expansion of the biomedical research knowledgebase on stress and stress-related illnesses with emphasis on the neurobiologyof stress.

Strategy 2.5.1. Expand basic research characterizing the neurobehaviorallinks between stress and risk factors for medical illnesses such as suppressionof the immune response.Objective 2.6. Effective strategies for prevention of adverse psychologicaloutcomes associated with deployments. Strategy 2.6.1. Conduct research on predisposing risk factorsfor adverse adjustment outcomes.

Strategy 2.6.2. Conduct research on the effectiveness of behaviorallybased protocols to reduce responses to stress.

Strategy 2.6.3. Conduct research on educational interventionsto prevent adverse health outcomes and prepare service members for expectedstressors during deployment.

Strategy 2.6.4. Develop pharmacological countermeasures to neutralizevulnerabilities to medical illnesses associated with extreme stress.
 Objective 2.7. Effective strategies for intervention during exposureto deployment-related stressors, with these interventions based on theprinciples of proximity, immediacy, and expectancy.

Strategy 2.7.1. Conduct research on the effectiveness of differentdebriefing protocols.

Strategy 2.7.2. Conduct research on the effectiveness of acutepharmacological intervention protocols.
 Objective 2.8. Effective treatments for the adverse psychologicaleffects of exposure to deployment-related stressors.

Strategy 2.8.1. Identify and assess the efficacy of a broadspectrum of treatment approaches.Research Priority Area 3. Emerging HealthConcerns

Objective 2.9. Targeted research programs on the potential healthconsequences of exposure to those materials, including mixtures of agents,for which toxicological data to establish exposure standards are lacking.

Strategy 2.9.1. Conduct periodic assessments of toxicologicaldata to identify data and knowledge gaps.

Strategy 2.9.2. Set priorities for research programs within DoD,VA and DHHS based on the periodic assessments.
 Objective 2.10. Maintenance of up-to-date information on the potentialhealth effects and the appropriate exposure standards associated with exposuresto materials comprising weapons systems.

Strategy 2.10.1. Appoint a single organization within theDepartmentof Defense DoD to serve as a clearinghouse for the aforementioned information.

Strategy 2.10.2. Create a centralized database containing theaforementioned information.
 Objective 2.11. Maintenance of a DoD database on the potential iatrogeniceffects of various disease prevention strategies, such as vaccines, andpesticides/insecticides, etc.

Strategy 2.11.1. Design, develop, and maintain the databaseusing the system under Objective B2.10 above.

Strategy 2.11.2. Periodically review, update, and report contentsof database.
 Research Priority Area 4. Infectious Diseases

Objective 2.12. Research directed toward attaining the lowestachievable incidence of infection during deployments due to endemic infectiousagents in the region of deployment.

Strategy 2.12.1. Support infectious disease research programs,with emphasis on threat assessment, rapid diagnostics, preventive measures(particularly vaccines that can be given before deployments), and improvedtreatments.Objective 2.13. Science-based deployment practices to achieve thelowest possible incidence of communicable infectious diseases generallyassociated with deployments. Strategy 2.13.1. Establish working group to evaluate scientificevidence that could result in changes in preventive medicine and treatmentpractices, for example, in the prevention and treatment of respiratoryinfections. The workgroup should identify research needs.Research Priority Area 5. Occupational RiskFactors and Non-Ccombat Injuries

Objective 2.14. Comprehensive research programs aimed at achievingsignificant reductions in non-combat injuries and illnesses during deploymentexperiences.

Strategy 2.14.1. Expand epidemiologic research on the underlyingcauses of motor vehicle and other transportation-related injuries.

Strategy 2.14.2. Develop countermeasures against excessive fatigueand sleep loss arising from rapid deployment and demands for 24-hour mobility.

Strategy 2.14.3. Undertake longitudinal studies of acute behavioraland neurological deficits (e.g., loss of attention or alertness, lack ofmotor coordination) associated with wartime toxic exposures.

Strategy 2.14.4. Develop valid portable tests for early, pre-morbid,identification of individuals exposed to toxic substances in the field.Supporting Narrative

The risk assessment/risk management paradigm shown in fFigure 1 providesa way of to viewing risk as arising from a number of sequential events,each of which contribute in some way to a health outcome. There are fFactorsassociated with each event that shape and determine the health outcome(determinants of response). For example, the patterns of troop movementin space and time determine how an atmospheric concentration is convertedinto exposure where exposure is defined as the intersection of a concentrationand a person or populations. Another factor that can determine responseto an agent is the iIndividual susceptibility of troops to that agent anagent also merits consideration. An example of this is exposure to an infectiousagent. TroTroops who are vaccinated against that an infectious agent willhave a reduced susceptibility be less susceptible to its effects.

Figure 1,The paradigm allows the identification of points at which prevention,intervention, and treatment strategies can be applied, and point to thehighlights specific research needs and actions that can help improve healthoutcomes from deployments. Although generic, fFiigure 1can be appliesdto a wwide range of exposures, including environmental toxins, contaminationby radiological materials, infectious agents, and stressorsSuch an applicationto a specific type of exposure or multiple exposures will help to identifyspecific strategies and actions.

Identification of research directed towards prevention, intervention,and treatment is accomplished by applying the risk assessment paradigmto a service member's life-cycle defined later in (fFigure 2). For example,exposure to stressors occurs during the immediate pre-deployment, deployment,and post-deployment phases., There are several time points in the life-cycleof the service member. during which mMitigation strategies can be applied.

The role of research is to identify potential mitigation techniquesand test their effectivenessAnother example is potential exposure to chemicalwarfare agents. In the case of potential exposure to chemical warfare agents,for example, Rresearch can help in the identifyication of effective meansof protection. Such means would include such as improved protective clothingand improved detection devices.

Finally, research directed at improved biologically -based dose-responsemodels is important to overall research efforts on causal relationshipsbetween exposure and response.

Setting Research Priorities for Goal 2

There are aA variety of health risk factors and exposures are associatedwith a military deployment. For this strategic plan to be effective, itis necessary to limit consideration of specific risk factors and exposuresto those that are considered most important. To accomplish this, the answersto tThe following questions were used to identify those exposures and riskfactors worth consideration for research purposes:

  • Based on best estimates,does could the risk factor or exposure cause widespreadmorbidity (and mortality) amongdeployed troops during or after deployment?
  • Is the degree of potential widespread harm high when balanced against theprobability that the risk factor (or threat) would be present during adeployment?
  • DoAre anticipated advancesments from research and development efforts havea high probability likely to of leading to significant reductions in morbidityand mortality?
  • Is current risk factor research within the military communitycurrentlyinsufficient?
The risk factors or exposures commonly associated with virtually any deploymentinclude:
  • Traumatic combat injuries (e.g., weapons fire and explosion, etc.).
  • Psychological stressors (e.g., psychological trauma, fear, and confinement,etc.).
  • Infectious diseases (e.g., endemic and non-endemic).
  • Unintentional injuries (e.g., vehicle collisions and falls, etc.).
  • Collateral health effects from weapons systems (e.g., exposure to propellantsand heavy metals, etc.).
Other risk factors, although less likely to be present during any particulardeployment, could pose a high degree of harm both in extent and severityinclude:
  • Intentional or accidental exposure to industrial high levels of hazardouschemicals – (i.e., environmental exposures).
  • Chemical, biological, and radiological warfare agent exposures.
Risk reduction should be the overriding focus in conducting research onthese risk factors. Risk reduction can be accomplished through prevention,intervention, and treatment, which can potentially be applied at all stagesof military life: induction, training, pre-deployment, deployment, immediatepost-deployment, and long-term post-deployment. Eachof these stages isconsidered in the context of research opportunities for improved risk reduction.

Research Area 1. Chemical, Biological, and Radiological Warfare Agents

Although there have been few documented uses of chemical, biological,or radiological weapons in combat during this century, a number of recentassessments confirm our concerns about their potential future applicationand thus the need for continued research. Due to their high degree of acutetoxicity, these agents have the potential for producing large numbers ofcasualties and/or markedly compromising mission accomplishment. In additionto protecting our service members from the effects of overt attacks withchemical or biological weapons (an area which has historically receiveda high degree of research attention), we must further examine the potentialhealth effects of incidental exposures which do not produce acute symptomsor diseaseneeds further examination. The ultimate goal of this researchis to attain the lowest achievable incidence and severity of either short-termor long-term injuries through a combination of detection, physical protection,and medical countermeasures.

Research Area 2. Stressors

Psychosocial stressors of all kinds are present in all phases of a deployment.It would be expected that the severity of health outcomes of stressorsis a function of exposure (amount and duration) and thus would vary fromdeployment to deployment. However, it is reasonable to assume thatno everydeploymentis without has stressors and the potential for both short- andlong-term health consequences.

Research Area 3,. Emerging Health Concerns

The armed forces are engaging in deployments to increasingly complexand novel environments with the potential for a variety of exposures withpotential health consequences. For example, deployments to heavily industrializedareas raise the potential for exposure to myriad industrial chemicals withtoxic potential. These potential exposures and combinations of exposuresmust be considered as potential deployment-related threats.

As weapons technologies change, new health concernsalso begin to arise.For example, the introduction of depleted uranium as a material in kineticenergy weapons to enable piercing of armor has created some concern overheavy metal toxicity and potential radiation effects. The military andveteran health communities must, therefore, be alert to these emergingtechnologies and be prepared to address health issues potentially associatedwith them at the earliest stages of development and implementation.

LastlyFinally, force protection measures, such as the use of prophylacticagents against biological and chemical threats, may carry with them potentialhealth consequences that must be weighed against their potential utility.Research must be specifically applied to ascertain such potential healthconsequences in military populations. Such knowledge will better informcommanders of risk and benefit associated with protective measures.

Research Area 4. Infectious Diseases

Infectious diseases are associated with all deployments. There are theproblems of infectious agents associated with poor sanitation and closeliving conditions. Then there are the problems associated with infectiousagents that are endemic to particular parts of the world and create uniqueand threatening health hazards, e.g., malaria, yellow fever, schistosomiasis,and leishmaniasis, etc. Effective prevention, intervention, and treatmentcontinue to be areas where significant advances can be made.

Research Area 5. Occupational Risk Factors and Non-Combat Injuries

Because physical combat injuries and their long-term sequelae have beena part of DoD and VA research agendas for decades, the value-added foradditional research in this area would be minimal. However, disease andnon-battle injuries (DNBI) associated with deployments currently accountfor the vast majority of deployment-related casualties.

This priority area focuses on issues of motor vehicle-related injuries,fatigue, and sleep loss, and the links between stress and health, as theyrelate to performance of service members in the field. This ensures thatthe spectrum of critical research needs concerning preventing occupationalrisk factors and non-combat injuries during deploymentare is addressed.The strategies, when taken together, should address the major non-combatinjury and occupational morbidity and mortality risks faced by servicemembers and during deployment.

Goal 3. The U.S. gGovernment will havethe capability to collect systematically population-based demographic andhealth data to enable longitudinal evaluation of the health of all servicepersonnel (active duty, reservist, nNational gGuard) throughout their militarycareers and after leaving military service.

Objective 3.1. An interdepartmentally coordinated, centralized,and computerized repository of health data, physical examination data,and laboratory analyses that would serve as the basis of a longitudinaldatabase for military personnel.

Strategy 3.1.1. Create an interagency coordinating body witha clearly defined charge and scope of responsibility and authority to providethe necessary interagency coordination.

Strategy 3.1.2. Develop the structure and detailed contents ofself-administered health questionnaires specific to different periods ofa service member's life--cycle beginning with the new recruit and extendinginto veteran status.

Strategy 3.1.3. Develop and implement a computerized system formonitoring baseline health status data on all new recruits.

Strategy 3.1.4. Fully implement the current system of routine,periodic self-administered health assessments during military service.
 Objective 3.2. Standardization of current data elements to facilitatetheir utility in forming relational databases to augment self-administeredquestionnaire data.

Strategy 3.2.1. Assess current data collection and storageactivities by each service with the purpose of encouraging standardizationacross services.

Strategy 3.2.2. Create relational databases of centralized computerizedadministrative, personnel and medical data sets, as they become available.

Strategy 3.2.3. Continue to maintain the existing centralizedbiological specimen bank.
 Objective 3.3. Mechanisms for long-term outcome follow-up afterdischarge.

Strategy 3.3.1. Longitudinally follow appropriate populationsof discharged individuals using self-administered questionnaires.

Strategy 3.3.2. Study feasibility of maintaining accurate post-dischargedata for service members' addresses. Create database if feasible.

Strategy 3.3.3. Extract data from other sources (i.e., VA PatientTreatment File, BIRLS Beneficiary Identification and Record Locator Subsystem,National Death Index, Medicare, etc.) and link with health assessment datadescribed above.
 Objective 3.4. Safeguards for protection of database confidentialityand of the basic human rights of all service members relative to the achievementof this goal.

Strategy 3.4.1. Develop guidelines for access to databases.

Strategy 3.4.2. Develop ethical guidelines for the collectionof information from service members.

Strategy 3.4.3. Develop ethical guidelines for the use of informationin the database for non-research purposeds.Supporting Narrative

Figure 2 illustrates the requirements to satisfy the overarching andrecurring need to be able to conduct population-based epidemiological studiesthat can compare pre- versus post-deployment health status. Ideally, asis shown in the figure, aAccurate health status data are desirable at allpoints during a service member's life--cycle.

It should be noted that the pre- and post- deployment health statusis a continuum with routine occupational exposures involving the same agentsas during deployment. Therefore, effects from multiple exposures (e.g.,from cumulative doses) must be assessed since these exposure patterns canlead to acute/chronic health outcomes and can have a direct bearing ondeployment-related health outcomes.

Figure 2

Essential to any longitudinalresearch activity on the impact of deployment cCollection of baseline healthassessment data on all military personnel is essential to any longitudinalresearch on the impact of deployment. This type of data forms the cornerstoneof any longitudinal database.

Already DoD has designed the Health Enrollment Assessment Review (HEAR)survey to collect personal information from MHS beneficiaries. Primaryilyhealth care personnel use this information to plan health care deliveryneeds.

Existing data elements that would be of use in tracking the health ofmilitary personnel include administrative, personnel, medical record, pharmacy,immunization, reportable diseases, physical profile, dental class, andother databases (see chapter 3). These should be standardized across servicesand data should be centralized. While these efforts would enhance the primaryutility of these data sets for their current uses, they would also enablethe data to be downloaded to the centralized database (described above).Banked baseline biological specimens are of considerable use in exploringtoexplore biochemical and genetic associationsas well to provide the potentialand make it possible to explore the interactions of lifestyle, medicalhistory, and biochemical, and genetic interactions. DoD has already initiatedsuch banking.

A large central repository of personnel and health data of militarypersonnel would allow investigators to propose research projects on targetedgroups of individuals. A mechanism should be put in place to make thesedata sets available for research purposes.

Goal 4. The U.S. Government will havethe capability to collect and assess data associated with anticipated exposuresduring deployments (also see chapter 3).

Objective 4.1. Simple and effective methods to assess exposuresof troops to environmental pollutants using personal, area, and biologicalmonitoring.

Strategy 4.1.1. Identify the organizations that collect informationrelevant to exposure on a regional and/or worldwide basis, and assess thecurrent extent of that knowledge.

Strategy 4.1.2. Determine spectrum of potential exposures.

Strategy 4.1.3. Compile in a computerized database all relevantenvironmental exposure and threat data on a country/regional basis.

Strategy 4.1.4. Determine the current state of the art for samplingand detecting various exposures and environmental media during deployments.

Strategy 4.1.5. Conduct research to develop smaller, lighter,simpler, more sensitive, and more rugged personal and area environmentalsamplers and detectors that are capable of measuring and/or sampling multipleexposures/chemicals at toxicologically relevant levels.

Strategy 4.1.6. Expand research in human biological monitoringto increase the number of chemicals that can be assessed and improve theanalysis time and data interpretation.
 Objective 4.2. Improved meteorological and dispersion models topredict environmental exposures to troops in the absence of actual sampledata or incomplete data.

Strategy 4.2.1. Survey and evaluate existing environmental,dispersion and meteorological models for their ability to predict exposuresto deployed forces.

Strategy 4.2.2. Expand the knowledge base of environmental modelingand the ability of models to predict accurately exposures to deployed forces.
 Objective 4.3. Methods for measuring exposure of service membersto psychological stressors.

Objective 4.4. Simple and effective methods to measure toxicologicallyrelevant exposures of service members to chemical/biological agents usingpersonal and area monitoring.

Strategy 4.4.1. Expand existing toxicological database to determinephysiologically relevant occupational and environmental exposure standards.

Strategy 4.4.2. Assess deficiencies in current technologies andpractices and develop essential equipment, methods, and procedures foroperational use.

Strategy 4.4.3. Develop passive detection capabilities for applicationas personal monitors or archival devices.
 Objective 4.5. Improved methods for tracking troops, both individualservice members and units, in space and time.

Strategy 4.5.1. Survey and evaluate the current methods andtechnologies being developed in universities, private industry, DoD, andother government agencies that are applicablefor to tracking individualtroops, troop units, and vehicles.

Strategy 4.5.2. Conduct research on potential methods, technologies,and systems capable of tracking and recording troop locations on an individualand unit basis, and that are capable of providing this information on areal time basis.

Strategy 4.5.3. Conduct research into systems capable of integratingtroop location data with exposure and medical outcome data, on as neara real time basis as possible and maintaining appropriate confidentiallyprotections.Supporting Narrative

There are a variety of exposures that troops experience during a deployment(environmental chemicals, occupational chemicals, stress, vaccines, pesticides,radiological,etc., or any combination thereof). Many of these exposuresare common to all deployments, whether they are peacekeeping missions oran actual armed conflict. Many are also the same, and at the same level,as the troops receive when they are at installations in the United Statesor stationed abroad. Current epidemiological research on Gulf War veterans'illnesses has frequently been hampered by reliance upon self-reported exposures,leading to reporting bias. Thus, deployment-related exposures potentiallyassociated with adverse health outcomes are important to measure directly.There is currently a certain level of exposure surveillance that occursduring major military deployments (environmental sampling, medical recordkeeping and questionnaires, serum samples, etc.). It generally employsnear state- of-the-art methodology, much of which is used by the civiliancommunity and government regulatory agencies in this country. There isalso a new DoD Directive and implementing Iinstruction on Jjoint MmedicalSsurveillance. Nevertheless, more work can and should be for exposure surveillanceduring military deployments. Much of this additional effort is dependentdepends on research that will provide expeditious methods of conductingexposure surveillance at the lowest operational level under battle conditions.Expanded research into development of biological markers of exposure wouldreduce the need for quantitative environmental monitoring under actualdeployment conditions and would provide better data about actual exposuresof individual service members.

The first priority of exposure surveillance is to determine the spectrumof potential exposures, and the resultant health outcomes that could occurduring a deployment. There is aA number of intelligence, environmental,health, and government agenciesthat partially fulfill this need. However,there is noone central system or source for this type of rapidly changinginformation. Before exposure surveillance needs and countermeasures canbe planned and carried out, the extent of the exposure threat must firstbe ascertained.

Many current methods of environmental monitoring require large cumbersomeequipment that have has extensive power requirements,are is often difficultto operate,are is sensitive to environmental conditions, andare isveryfragile. These characteristics clearly make this equipment unsuitable formost of the environmental monitoring that occurs during a deployment. Muchof the smaller, simpler equipment does not have the required sensitivityto detect low levels of chemical contamination. Once we know the potentialexposures that exist during a deployment,it is we mustimperative that wedetermine the actual type and level the troops really encounter. Only withthis information available can we determine if the health outcomes experiencedby troops are related to the exposures they experienced during a deployment.

Often it is notIt is seldom possible to collect quantitative data whenan exposure incident occurs. The data also may be inadequate from a spatial,temporal, or sensitivity standpoint. Therefore, it is often necessary toreconstruct the exposure by modeling the incident. Currently, nNumerousenvironmental models are used to predict exposure. However, their accuracyand precision are sometimes questioned and their ability to handle differentchemicals and atmospheric conditions can be a problem. In the absence ofactual exposure data, model predictions are critical to determine if healthoutcomes that troops experience during and following deployments are associatedwith environmental exposures.

To determine the exposure of service members using environmental modeling,area monitoring, or exposure incident proximity, it is necessary to knowtheir locations at the time the possible exposure occurred. This task isdifficult Wwith the present systemthat is now a difficult task to accomplish.. Currently troop location data are on a unit basis and are generally compiledfrom paper records after the deploymentis over. Therefore,improvementsto the system must be made improved to characterize better the exposuresthat occur during deployments and the potential medical outcomesbetter.

The ultimate objective of environmental exposure monitoring and assessmentis to determine whether there are associations between exposures that occurredduring a deployment and adverse health outcomes in deployed troops. Tomake this determination we must be able to catalogue the exposure thatan individual service member receives and link those data to individualhealth records. To accomplish this objective we must create a computerizeddatabase that stores all relevant exposure data for an individual and iscapable of linking those data with individual health records, to determineif exposure is responsible for adverse health outcomes. It may, however,never be possible to capture all the relevant exposure data that may beneeded to determine if an exposure is responsible for an adverse healthoutcome.

Goal 5. The U.S. Government will havea reasonable capability to monitor deployments for the appearance of novelor unanticipated health risks and to deploy quickly the means to collectand assess data relevant to such threats.

Objective 5.1. Mechanisms to determine, before all deployments,the potential for novel exposures associated with a deployment region.

Strategy The U.S. Government, under the leadershipof a group formed by theas advised by a working group chaired by the NSC,National Security Council (NSC), should integrate organizational expertiseto identify and assess the potential for novel or unanticipated exposuresassociated with major deployments or large scale contingency operations.Objective 5.2. Personnel, resources, and equipment will be availablebefore a deployment to collect the data necessary to assess these novelexposures. Strategy 5.2.1. The NSC chaired working group should make recommendationsfor research on sampling and detection equipment to address their requirements.

Strategy 5.2.2. Before a deployment, DoD should assemble andprepare for deployment the necessary equipment and personnel to rapidlycollect and assess data associated with exposures. These assets must beavailable and capable of deployment to protect U.S. forces.
 Objective 5.3. Methods, models, and systems that permit better andmore timely assessment of potential biological and health responses tonovel or unanticipated exposures, especially for complex or combined exposuresand unusual exposure conditions associated with military operations.

Strategy 5.3.1. Based on intelligence input, develop researchapproaches that permit more timely screening or assessment of potentialagents and combinations of agents (biological, multi-chemical, physical,stress) for harmful outcomes prior to deployments in order to establishoperational exposure limits.

Strategy 5.3.2. Develop deployable (compact, rugged, simple)screening or test systems that can rapidly assess the potential biologicaland health responses to novel or unanticipated exposures and exposure conditions,including complex, mixed exposures.

Strategy 5.3.3. Conduct research needed to develop more sophisticatedlaboratory test systems that can be used post-deployment to evaluate experimentallythe biological and health responses to exposures encountered during deployments.Supporting Narrative

When exposures can be anticipated, mechanisms to measure and assessthem are theoretically possible (see above). Indeed, deployment plannersknow the vast majority of deployment-related exposures, and appropriateresponses to these exposures (e.g., medical intervention, protective equipment,environmental monitoring, etc.) are planned and executed during the deployment.However, the unpredictable nature of war can lead to unexpected or novelexposures. If possible, mechanisms to anticipate and measure novel or unanticipatedexposures should be available.

Goal 6. The U.S. Government will maintaina wide range of national and international collaborative relationshipsto enhance research efforts.

Objective 6.1. Maintain an ongoing interdepartmental review ofand input into research strategies and programs for preventing and reducingadverse health outcomes associated with military deployment.

Strategy 6.6.1. Establish a permanent interdepartmental researchcoordinating body, consisting of scientists and senior managers fromtheDepartments of Defense DoD,Veterans Affairs VA, andHealth and Human ServicesDHHS, and other agencies as appropriate. This committee will meet on routinebasis to ensure continued implementation of the current research strategy.

Strategy 6.6.2. Provide liaison to the National Security CouncilNSC and the Office of Science and Technology Policy (OSTP) to ensure appropriatestrategies are in place to address unique health concerns associated withspecific deployments in support of the National Military Strategy.

Strategy 6.6.3. Integrate available intelligence into threat-basedresearch protocols.
 Objective 6.2. Establish and maintain appropriate collaborationsbetween U.S. and international investigators.

Strategy 6.2.1. The interdepartmental research coordinatingbody should work with ongoing international strategic research alliancestructures.

Strategy 6.2.2. The interdepartmental research coordinating body,along with its international partners, should ensure appropriate exchangeof information on the most effective research strategies for preventingand reducing adverse health outcomes associated with military deployment.Supporting Narrative

Research on deployment-related health issues spans a wide array ofresearch areas. In order t To maximize the efficiency of research investigationsand the application of research to deployment health problems, it is importantthat deployment-related health research efforts engage appropriate governmentresearch sectors, university-based research, private research, and researchconducted in other countries. Only through coordinated efforts with allsectors of research, nationally and internationally, can significant progressbe made in this area.

Ongoing interdepartmental input and review is essential for ensuringthat an appropriate research strategy based on the most current scientificknowledge is implemented. Planning for special meetings associated withspecific deployments is equally important as not all health outcomes orenvironmental exposures can be anticipatedin advance.

Many countries have considerable experience in addressing the healthconsequences of military service. A priority should be placed on establishinga mechanism for ensuring collaboration with international research organizations.Such collaboration amongUnited States U.S. and international investigatorswill enhance U.S. efforts to address the health concerns of its militarypersonnel by ensuring that new scientific findings are integrated intothe research strategy in a timely manner.


Although eachof the Goals, Objectives, and Strategyies is important,it is necessary to identify priorities. The goals related to data needs(Goals 3-5) are crosscutting across all aspects of deployment health and,therefore, of highest importance for deployment health.

Althoughthe availability of population and exposure data is a prerequisitefor much research, the acquisition and maintenance of such data are not,per se, research. Thus, within the narrower context of research, additionalpriorities need to be set. Of the two primary research goals identified(Goals 1-2), Goal 1 is the highest priority. Maintenance of the capabilityand capacity to conduct deployment-related epidemiological research ensuresthe continued flow of vital information needed to assess the health consequencesof deployments, and to stimulate new research directed toward improvedprevention, intervention, and treatment strategies.

Goal 6 is an organizational priority requiring not so much a commitmentof resources as but a commitment of will to engage a wide range of nationaland international scientific communities in this endeavor. Therefore Basedon its, minimal cost, but and potentially high impact, of Goal 6 arguesfor it receiving should receive high priorityconsideration.

Within each goal of this research strategy, objectives are listedin order of importance to the goal. Likewise, within each objective, strategiesare listed in order of their importance to the objective.

Chapter 5



The Federal Government has an unwavering obligation to care for thehealth of those placed in harm's way to defend the vital interests of theNnation. Therefore, the Federal Government must be able to respond promptlyand effectively to the health needs of our military, veterans, and theirfamilies. In particular, when health problems are identified followinga military deployment, plans must be in place to improve and facilitatecooperation and coordination among DoD, VA, and DHHS, as well as amongother appropriate agencies of the Executive Branch. This report, preparedin response to PRD/NSTC-5, provides the first comprehensive set of recommendationsdesigned to help ensure that this obligation is met in a manner that takesinto consideration the successes and failures of past deployments.

The numerous goals, objectives, and strategies contained in the reportprovide a roadmap to improve the health preparedness associated with troopdeployments. Each strategy recommends specific actions needed to achievethe stated goals and objectives. This chapter provides the IWG's assessmentof the major recommendations that emerged from its deliberations.

These recommendations can be divided into two main categories:

  • Recommendationsdesigned to that improve coordination across DoD, VA, andDHHS on a continuous basis.; and
  • Recommendations that require agencies to adopt changes that may requireinteragency coordination, but are more dependent on significant programmaticchangesoccurring within agencies.

Creation of a Military and Veterans HealthCoordinating Board

To achieve many of the goals laid out in this plan, there must be ongoingcoordination of all agencies involved in maintaining the health of militarymembers (active, guard and reserve component), veterans, and their families.This could be accomplished through the creation of a Military and VeteransHealth Coordinating Board (MVHCB). Once established, the MVHCB would ensurecoordination between the VA, DoD, and DHHS on a broad range of health careand research issues relating to past, present, and future military servicein the U.S. Armed Forces.

To be optimally effective, the Board should be chaired by the Secretariesof VA, DoD, and DHHS. Representation on the Board should include policyand program level staff from these departments as well as liaison representativesfrom veterans service organizations and other agencies, as deemed necessary.Note, for example, that the U.S. Coast Guard functions as part of the U.S.DOT except in time of war, when it becomes part of the U.S. Navy. Representationon the Board from DOT is appropriate.

The work of the Board must take into account that National Guard forcesafter a deployment are the responsibility of their respective state governments.It must also take into account that state and community public health officialshave roles and responsibilities related to the health of veterans and theirfamilies residing in their state. States and communities may be responsiblefor the health and health care of veterans and their dependents who choosenot to use VA health care services. In addition, health problems in thepopulation that are not initially recognized as being associated with militaryservice may first come to the attention of the state and community publichealth officials. In these cases, the states may call upon various componentsof DHHS to assist in responding to such health problems.

The Board should provide oversight, coordination, and linkages to otherrelated efforts in the fFederal gGovernment in the areas of deploymenthealth, health care, research, health risk communication and education,record keeping, and compensation. The Board should establish working groupsto carry out its mandate.


The MVHCB would make information available as needed to other ExecutiveBranch agencies, the Congress, the medical and scientific community, andthe public. It is critical to the success of the Board that it adopts aninclusive mode of operation. In addition to other fFederal gGovernmententities, the Board must have effective avenues of outreach to veterans'service organizations, scientific professional societies, the press, stateand community governments, and our Nation's international partners. Aspart of its outreach mission, the MVHCB would develop and implement a protocoland infrastructure for establishing an integrated electronic web page tocommunicate health information related to future combat operations.

The Board Staff

To be effective, the MVHCB will require a dedicated staff that is committedto achieving the goals and objectives detailed in this interagency plan.At a minimum, the Board will require one full-time professional in eachof the following positions: executive director,medical director militarypublic health officer, health scientist, health risk communication specialist,and administrator/program analyst.

Creation of an Information Management/InformationTechnology Task Force

DoD and VA, in consultation with DHHS, will establish an InformationManagement/ Information Technology Task Force (IM/IT Task Force) to providedirection and coordination for health and personnel information managementand record keeping activities, especially activities associated with combatoperations and deployments. The primary responsibilities of this Task Forcewill be toas follows:

  • Monitor the development of health and personnel data requirements by theDepartments and by the Military and Veterans Health Coordinating BoardMVHCB Working Groups identified in this plan.
  • Incorporate necessary IM/IT standards to ensure the accurate and efficientinformation exchange between DoD and VA of health data and deployment-relatedpersonnel and exposure data;
  • Support electronic capture, storage, and transfer of deployment-relateddata; and
  • Coordinate interagency health and personnel IM/IT efforts.
The Task Force members will meet with MVHCB Working Groups and incorporatefunctional information requirements defined by MVHCB Working Groups intodata models and integrate data sets into existing or planned IM/IT activities.


In addition to identifying the need for ongoing interagency coordination,each Task Force developed strategies, which in essence are recommendationsfor continuing or new actions to achieve goals and specific objectives.The IWG identified the following recommendations emanating from the interagencyplan that clearly represented essential strategies for successfully meetingthe broad objectives of thePresidential Review Directive PRD.

Deployment Health

  • The Joint Staff and the military services shall complete implementationof the DoD dDirective and iInstruction on joint medical surveillance byDecember 31, 1998.
  • DoD and DHHS (FDA) should acceleratetheir efforts to not only identify regulatory issues associated with theuse of investigational products during military exigencies, but also developstrategies to resolve them. Although relevant in some cases, use of investigationalproducts by civilians, for example as countermeasures for domestic terrorism,is outside the scope of this activity.
  • DoD shall proceed with its contract withthe National Academy of SciencesNAS andthe National Research Council NRC for a 3-year program of scientific,technical, and policy analysis activities entitled "Strategies to Protectthe Health of Deployed U.S. Forces" that is scheduled for completion inSeptember 2000.
  • DoD, in consultation with DHHS, shallestablish a pilot conduct a studyto determine the feasibility of establishing a program to conduct birthdefects surveillance among beneficiaries of the MHS in San Diego County,California, by September 30, 1998.
Record Keeping
  • DoD shall continue to execute and develop implementation plans based onthe DoD MHS Strategic Plan, the Medical Readiness Strategic Plan (MRSP).
  • DoD shall continue toexecute implementation of implement the recommendationsof the Defense Science Board Task Force on Military Personnel InformationManagement to design, develop, and implement the Defense Integrated MilitaryHuman Resources System (DIMHRS).
  • DoD, in consultation with VA and DHHS, will ensure that the DIMHRS databasecontains and maintains service member's demographic, occupational, andmilitary experience data in a longitudinal record that allows transferof pertinent data among DoD systems and VA by 2004. When pertinent, quantifiabledata on personal occupational, environmental, and deployment-related exposuresand events shall be included.
  • DHHS, VA, and DoDshall will establish post-deployment registry templatesand data systems by June 30, 1998 December 31, 1998.
  • DoD and VA, in consultation with DHHS, shall establish a Recruit AssessmentProgram to develop and maintain comprehensive electronic health and riskfactor information on all recruits and officer accessions at the time ofinitial military training, in a manner that pertinent information is transferablebetween DoD and VA by September 31,30, 2000. The program shall be pilottested by June 30, 1999.
  • VA and DoD shall establish a computer-based patient record that will accuratelyand efficiently exchange information between DoD and VA.
Health Risk Communication
  • VA, DoD, and DHHS should develop and implement a coordinated interagencyhealth risk communication program .to communicate The program will conveyto military members, veterans, family members, and the public health riskinformation related to current and future deployments, especially combatoperations. health risk information related to current and future deployments,especially combat operations, to military members, veterans, family members,and the public by March 31, 1999.
  • DHHS, VA, and DoD, in consultation with DHHS, will develop and implementan interagency applied research program on health risk communication formilitary members, veterans, and their families.
  • DHHS, VA, and DoD will assess the feasibility, options, and costs to expandthe build essential capacity for electronic communications with state andcommunity public health departments to enhance the dissemination of healthrisk information to veterans and their families through local public healthinfrastructures.
  • DHHS, VA, and DoD will assess the feasibility, options, and costs to providetraining to local public health officials on the use of essential informationtechnologies to disseminate and receive health risk information from veteransand their families.
  • DoD and VA shall maintain a robust, biomedical RDT&E research, development,testing, and evaluation program emphasizing research priority areas identifiedby the PRD-5, including medical counter measures for chemical, biological,and radiological warfare agents; stressors; emerging health concerns; infectiousdiseases; and occupational risk factors and non-combat injuries.
  • DoD shall consider for funding, under the Defense Program Element for GulfWar Illnesses (GWI) Research, Fforce Hhealth Pprotection research initiativesthat will help preclude GWI-like health outcomes following future deployments.Such initiatives may include deployment health related research, population-basedtroop health assessments before, during, and after deployments, and epidemiologicalresearch to determine whether deployment-related exposures are associatedwith post-deployment health problems.
  • DoD shall facilitate external technical reviews of Fforce Hhealth Pprotectionscience and technology initiatives.
  • DoD shall ensure that military medical manpower requirements include scientiststrained in the medical specialties essential for Fforce health Pprotectionresearch including epidemiologyist, preventive medicinespecialist, andpublic healthpractitioners.


Appendix A

AGuide to Health Risk Communications


This appendix provides a planning guide for health risk communicationsmanagers and planners involved during the training, pre-deployment, deployment,and post-deployment stages of a given military exercise or peacekeepingmission.

The planning guide is designed to help:

  • Improve an organization's ability to develop and deliver health risk andhealth communication messages;
  • Strengthen an organization's communication skills and confidence in itscommunication ability; and
  • Improve an organization's ability to protect the health status of the intendedaudience using effective communication techniques.
Whether a large unit or a smaller field unit,tThis guide will help in theassessment of the capacity of an organization whether a large unit or asmaller field unit to implement health communication projects, analyzea unit's working environment, and plan to increase the effectiveness ofhealth communication interventions.


This guide presents a diagnostic process that involves a series of basickey communication elements organized by the six general goals and relatedobjectives and strategies necessary to develop and implement a successfulcommunication activity.

Completion of the six- goal planning process will identify areas ofneed and opportunity for your organization and provide a structure to leadthe reader through an effective health risk communication process. A majortheme of this process is involvement of the intended primary and secondaryaudiences as well as appropriate external partners in both the identificationof their needs and the selection of communication messages and strategies.


Although this guide is intended for communication managers, the organizationaldevelopment process works best if other staff members, the intended audience,and, when appropriate, external partners have input into key planning discussions.By involving these groups,you one receives realistic feedback from theintended audience, external partners, and the field personnel responsiblefor much of the intervention work.


This strategic planning guide can be used for occasional communicationsupport, choosing a strategy, or planning an idea that is needed at a givenmoment. However, to be most effective field personnel should test thisprocess in the intended environment. Results and necessary adjustmentsshould then be folded into a continuing staff training program for healthcommunication personnel. Above all, these materials provide a planningstructure that must be continuously modified based on the realities ofthe communication environment.


Goal 1. Develop a health communicationplan and select a strategy.

The planning stage of a program provides guidance for managingthe entire health communication process. Planning is a systematic and creativeprocess in which information, attitudes, and ideas are managed to be exchangedand transmitted via specific messages and channels. The efforts to shapeand disseminate messagesin order to accomplish established objectives andgoals become the elements of communication planning. Careful assessmentof a health problem and strategy selection in the beginning of the processwill reduce flawed decision making and improve outcomes.

Objective 1.1. Develop a written purpose statement.

The first component of a sound communication plan is a written purposestatement based on a thorough understanding of the health problem as dealtwith by those expected to be most burdened— - the intended primary audience.Good planning will help with identification of the audience's beliefs andcurrent behavior regarding the health problem., which in turn will serveto define the feasible behaviors that the communication intervention willask the intended audience to know and perform. The health communicatorturns the expected knowledge or behavior of the audience into specificcommunication messages with specific objectives. These messages are translatedinto communication materials (print, video, electronic, etc.) and pre-testedin the field with a sample of the recipient audience. Final disseminationof health messages is based upon a clear health problem statement, pre-testedmaterials, andclear achievable communication objectives.

Objective 1.2. Assessyour the environment.

Before developingyour a communication program, it is importantfirstto complete an analysis ofyour the operating environment. This externalassessment will provide an overall picture of who is active in the communicationarea, whereyou one might find support foryour the activities, how to avoidduplication of efforts, and the human and resource capacity to actuallydevelop and manage the communication intervention within your organization.The answers to the following questions will help guide your assessment:

  • Whatare the groupsthat may interact withyour the organization?
  • What is the relationship of these groups toyour the organization?
  • Who are or should be the primary and secondary audiences foryour the currentand future services?
  • Who are the key decision makers affectingyour daily work?
  • What are the health interventionsthat doesyour each unit plans to address?
  • What areyour the key funding sources?
  • What other organizations both internally and externally arecurrently involvedin similar health interventions and are working with the same audience?
  • How can your organization's relationships with other groups be strengthenedto increase audience support?
Objective 1.3. Develop a written health problem statement.

Early in the planning processyou one must set priorities anddefine developa health problem statement. One Ddefines this problem by asking yourselfthe following questions:

  • What is the health problem (e.g., mortality, morbidity prevalence, geographiclocation, etc.),? including wWhat is happening, where and when, to whom,and with what effects?
  • What are the risk factors related to the problem?
  • What are the anticipated obstacles?
  • What are the known problem causes and preventive measures?
  • What information is needed (e.g., gaps analysis, research plan, etc.)?
  • What resources are readily available?
Objective 1.4. Develop a written health communication strategicplan.

Developing a written health communication strategy forces the healthcommunicator to consider all the elements of the strategic planning processIndeveloping a written health communication strategy, the health communicatormust consider all elements of a strategic planning process (overall strategystatement, dissemination strategy, written communication objectives, andhealth messages). and to place them in a strategy that will give the targetaudience the motivation to understand and act upon the proposed communicationproduct. The elements of thehealth communication strategic plan may varyconsiderably as the environment changes from training, pre-deployment,deployment, and post-deployment phases.

TheA health communication strategic planis composed includes of thefollowing elements:

  • A strategy that encourages the health communicator to see interventionsfrom the point of view of the intended audience (recipient);
  • The selection of strategies for developing communication objectives andmessages;
  • Identification of communication channels (e.g.,, print, electronic,video, face-to-faceetc...) and their accompanying materials for disseminatingmessages;
  • Information delivery systems that are creative and cost effective for distributingmaterials and receiving feedback from the intended audience; and
  • A realistic, comprehensive tracking system thatprovides provides for monitoringingand evaluation ion of the communication intervention.
Implementation Strategies Strategy 1. Establish within DoD both administrative leveland unit (or installation) level health risk communication teams responsiblefor health risk communications during the training, pre-deployment, deployment,and post-deployment phases. The administrative teams should oversee theactivities of the local or installation level team.

Strategy 2. Develop guidelines to identify generic threats commonto all deployments. Establish appropriate health risk communication strategiesfor each generic threat.

Strategy 3. Develop interdepartmental guidelines for writinghealth communication problem statements and a quick-response mechanismto integrate new threats.

Strategy 4. Link surveillance data with communication planningas troops movements change during deployment.

Strategy 5. Develop a written guidebook that details how post-deploymentservice personnel and veterans can continue to receive health informationand communicate their health concerns to medical personnel.

Strategy 6. Develop a strategic communication media planningguide that will be used to answer the "who, what, where, when, why andhow" types ofquestions.
 Goal 2. Analyze and segment intended audiences.

Audience analysis is the gathering, interpretation, and applicationof demographic, behavioral, and psycho-graphic information related to audienceinterest.

Segmentation is the process of breaking down a largeintendedaudience into a small number of subgroups that are internally as homogeneousas possible and as different from each other as possible. Dividing a largepopulation into homogeneous subsets of priority audiences helps to betterdescribe and understand a segment, Segmentation makes it easier to describeand understand each subset, predict behavior, develop tailored messages,and meet specific needs. Segments may be demographic (e.g., age,sex, education, etc.), geographic (e.g., theater of service, physicallocation in post deployment stage, etc.) or psycho-graphic (e.g., medicalusage patterns, risk factors, health status, benefits sought, informationpatterns, trusted sources, etc.).

Objective 2.1. Describe and segment intended audiences.

Risk communicators need to be especially alertto describe the in describingtheir audience(s). that are to receive the communication intervention.Few messages are appropriate for everyoneincluded in the military populationgiven the diverse interests, needs, concerns, and priorities during thevarious stages of training, deployment, and post-deployment. Trying toreach all recipients with one message or strategy is rarely successfuland tends to dilute the message. Single message dissemination may onlybe appropriate when the intent of the communication is merely to raiserecipient awareness.

The four major purposes of audience segmentation are as follows:

  • Decide resource allocation;
  • Develop important delivery profiles based upon key characteristics of therecipient;
  • Devise communication strategies based upon audience profiles; and
  • Develop audience-specific messages and pre-test.
The health communication team must think carefully about the feasibilityof the segments chosen. Linking feasible health risk communication activitiesand appropriate audiences will help focus activities on disseminating usefulinformation for individual decision making. In addition, segmentation canincrease the confidence and the credibility of the health risk communicationteam and demonstrate their trust and effectiveness of their message andstrategy selection.

Objective 2.2. Apply segmentation criteria to segment audiences.

Useful criteria for choosing audience segmentsto focus as focuses fora communication intervention include the following:

  • Audience segments most affected by the health problem (e.g., healthstatus, exposure registrants, seriousness etc.);
  • Size of the segment;
  • Availability of outside partners and resources to assist in dealing withthe problem;
  • Ability of the audience segment to cope with the problem and the levelof assistance needed; and
  • Accessibility, availability, and willingness of the audience.
Objective 2.3. Develop working relationships with important partners.

Organizational partners from within a particular community can provideaudience insight and key information that will help communicators designand implement health communication interventions. These sources includeinfluential local leaders, private veterans groups, local health professionals,and special interest groups.

Network partners can help solve the numerous communication problemsthat will emerge and can provide needed support and comfort to the primaryaudience. These sources include health professionals, family members, andreligious groups.

Media partners can effectively and efficiently reach a large audience.Coverage of a health issue in the media can increase the salience of thetopic in people's minds. These sources include local and national print,audio, video, and electronic groups.

Objective 2.4. Use field experience to improve your audienceoutreach.

Appropriate identification of the intended audience at the start ofa program results in a much more cost- effective and successful intervention.After the initial health problem has been described, it is necessary toidentify the primary and secondary audiences involved in the problem andto learn more about their behavior through field research. The use of localorganizations and specific geographic databases, which provide much neededpsycho-graphic information, can assist message development and channelselection to reach identified recipients in the post-deployment stage.Strong partner identification, outreach, and selection techniques are allnecessary to gather the most useful information from the intended audiencesto plan the communication intervention.

Implementation Strategies

Strategy 1. Develop guidelines for determining primary andsecondary intended audiences.

Strategy 2. Establish advisory mechanisms to involve intendedaudiences, to assist needs assessment, and to improve information disseminationand retrieval.

Strategy 3. Develop an electronic information system tobettersend and receive information better.

Strategy 4. Encourage "science literacy" by integrating baselineservice member "health and science information" with basic/advanced training.

Strategy 5. Develop a self-administered "science based" questionnairespecific to the service member life cycle.
 Goal 3. Select appropriate messages andchannels.

Messages are the essential communication themes and ideas thatare delivered by the communicator and acted upon by the recipient. Channelsdescribe the route of message delivery (e.g., mass media, face -to- face,print, electronic, video etc.). Channels should always be considered astwo-way vehicles for transmitting information.

Objective 3.1. Explain the "what, so what, why now, and now what."

Good messages depend on knowing the audience,and what it wants to know,and what steps it might take. An effective message has three main purposesasfollows:

  • Explaining the W"what?" The basic risk information being conveyed—itmay be factual information, it may break down expected audience reactionsinto small steps, or it may directly address a concern or problem by offeringalternatives or solutions.
  • Explaining the "Sso Wwhat, Wwhy Nnow?" The reasons or benefits foraction. Specifically, what are the health benefits and incentives for action?What action is important now and why is it compelling? What is the threatif current inaction continues? What are the immediate benefits to the intendedaudience?
  • Explaining the "Nnow Wwhat?" Clearly defines some desirable andproductive action by the intended audience. It may mean seeking out furtherinformation, reaching out to someone or some important network or organization,or taking a small step to "test the water" of some proposed solution.
Objective 3.2. Use written criteria to develop health risk messages.

Not allof the messages can be transmitted at the same time. The communicationteam will need to set priorities for the messages and select those thatare absolutely necessary for initial knowledge and effective first trial.As the target audience learns and acts on the messages, the communicatorcan deliver other messages in succeeding phases.

How does the communication team define the messages to be used in ahealth communication intervention? Important criteria for successful messagedevelopment include the following:

  • Emphasize information relevant to practical actions that recipients cantake;
  • Emphasize clear, concise message themes written in plain language; and
  • Develop messages initially to inform recipients about a health concernwhile research is underway or information is being gathered. As the environmentchanges and more health risk data becomes known, provide useful informationfor audience decision- making.
Objective 3.3. Address message elements of special concern.

The health risk communicator should be aware of special elements thatmust be addressed for message development and delivery. These elementsare as follows:

Uncertainty: Health risk messages and supporting materials shouldnot minimizethe existence of the scientific uncertainty of a given riskfrom an identified hazard. Research needs and data gaps should be acknowledgedup front, as should any disagreement among experts. The level of confidenceof risk estimates should be conveyed in the format, style and "mental model"of recipients.

Comparing Risks: Risk comparisons can be helpful in message development,particularly among scientists and risk managers. In health communications,there are proven pitfalls when risks of diverse character (e.g., seat beltuse, smoking cessation, etc.) are compared with chemical or safety hazards,especially when the intent of the comparisoncan be seen as minimizing isintended to minimize health risk. Multiple comparisons that list a specificrange of known health effects and exposure conditions may provide moreuseful and trusted information.

Multiple Messages: In mMost health risk communication interventionstherewill be include multiple messages which that concernreporting risk analysisissues,special interestsissues, value questions, and trustissues. For this reason,tThe health risk communication development process includes the full rangeof messages. Thus, a health risk message designed to convey informationregarding a specific finding may also need to address issues of audiencevalues and communicator credibility. To the extent feasible, the healthrisk communicator should anticipate and plan for these multiple messages.

Theme Line: For all audiences, the message should prominentlypresent a summary statement that captures the main idea, theme, or finding.Distillation of key theme lines is critical in reporting findings of scientificresearch.

Vividness: For most audiences, messages should use lively language,striking but accurate statements, relevant facts, and appropriate visuals.

Appropriateness: Risk information delivery should be consistentwith the general norms and preferences of the intended audience.

Objective 3.4. Pre-test messages with the intended audience.

The communication strategic plan and the information collected duringthe audience analysis and segmentation process provide the blueprint fordeveloping message concepts. These concepts should be consideredin "rough draft" until they can be tested with a representative sampleof the recipient audience. Pre-test each message concept to make sure itcomplies withyour the communication strategy and objectives. Consider testingalternative concepts with the intended audience to help predict the impactof scientific information or testing the message with a group of volunteersto better clarify how the health risk information will impact the public.Pre-test the messages well in advance of final message development to allowample time to make appropriate modifications. Plan for the modifications.

Testing message and materials should provide the communication teamwith the following:

  • Assessment of message comprehension and delivery mechanisms;
  • Identification of strong and weak points of message themes;
  • Determination of personal relevance to the audience segment;
  • A gauge of unclear, sensitive, or controversial elements;
  • Identification of language used by the recipient audience; and
  • A channel for intended audience input and feedback.
Objective 3.5. Select the appropriate channel.

It is important to consider what type of communication channels is bestsuited to achieve different objectives. Generally, media and electronicmail are the least interactive method to reach people, but are appropriatemechanisms to disseminate simple one-way messages. Face-to-face communication(by a trusted commander, trainer, health professional,etc. for instance)allows for much greater audience participation. Use face-to-face messagesfor situations where the audience needs feedback and an opportunity toshape the communication. Face-to-face meetings in small group settingsserve as an appropriate venue for providing detailed health information.This mechanism is particularly appropriate during the training, and deploymentphases.

Special community meetings, town hall sessions, and conferences sharecharacteristics of both media and face-to-face communication. Town hallsessions often provide a good opportunity for recipient feedback; however,communicators should expect concerns about vested interests and value differences,as well as general mistrust of expert knowledge seen often as serving a"special interest."

Finally, 800 numbers and electronic mail provide an effective way todisseminate information in large quantities and in a timely manner. However,because many audiences may have access problems, use intermediaries (e.g.,local librarians) to assist recipients to "get on line." "Chat rooms" providea mechanism for two-way electronic exchange of information, but they aresusceptible to message overload from multiple sources.

Base the ultimate decision inUltimately, selecting channels based onwhatyour the intended audience already listens to, views, or reads.

Objective 3.6. Use different types of channels.

Consider the following channels in selecting the mix of delivery mechanisms:

  • Face-to-face: one on one communication, home visits, group discussions,counseling, or town hall meetings.
  • Written documents and audio-visuals: pamphlets, fact sheets, point-of- contact displays, videotapes, or slides.
  • Electronic and Mmass Mmedia: Radio, television, newspapers, magazines,FAXfax, Internet, Intranet, or 800 numbers.
Objective 3.7. Use criteria for selecting a channel of communication.

Develop communication dissemination activities that will indicate thefollowing:

  • Which channels the intended audience uses, trusts, and has access to;
  • Which channels are most effective for communicating research findings;and
  • Which channels are best for delivering the type of information the audiencewants to receive.
Match the ability of the channel to deliver the message by applying thefollowing elements:
  • Is the channel of communication a trusted source of information for motivatingrecipients to learn new information or adopt a behavior?
  • Does the communication format lend itself to the content of the message?For example, fact sheets may be effective for some content but expert two-waydialogue may be required to support research findings.
  • Is the desired language more visual, written, or sound based? Is it a combinationof all three?
  • Will the channel reach the intended audience at the level of depth needed?For example, introducing a new health research project of broad interestmay require a more general information activity (TV and radio) than thediscussion of a health research finding of most interest to (primary healthcare providers).
Analyze the frequency and reach of the selected channel as follows:
  • Which and how many people need to be reached? What is needed at what momentin the communication strategy?
  • What is the frequency of message repetition? Some channels,, like radio,can repeat a message up to15 times per day at a reasonable cost.
Develop a written inventory of administration costs and potential barriers.
  • What can be accomplished with current personnel and other resources available?What networks and organizations can assist information delivery?
  • Some channels are more costly than others are. What are the tradeoffs?Is the goal to transmit a simple message or to ask the intended audienceto adopt a certain positive health behavior?
Implementation Strategies Strategy 1. Define guidelines and criteria for developing appropriatecommunication messages and channels.

Strategy 2. Use extensive outreach mechanisms (focus groups,intercept interviews, surveys) to determine the general channel preferencesof the audience(s).

Strategy 3. Develop links with external public health communicationexperts who will provide advice and assistance in developing and pre-testingmessage and channel selection.

Strategy 4. Conduct or sponsor research to determine communicationresearch factors that improve message development and are determinantsof positive outcomes.

Strategy 5. Use POM (preparation for overseas movements) activitiesas an effective communication channel.

Strategy 6. Develop channel mechanisms to provide informationto all training units and interested network, media, and partner groups.

Strategy 7. Develop "easy- to- read" single page fact sheetsfor hazardous exposures or safety issues of concern.

Strategy 8. Work with the American Library Association to linklocal libraries and their electronic media resources to serve veteransand veterans service organizations.
 Goal 4: Develop written communication objectives.

Goal 1 outlinesd the importance of strategic planning and general goaldevelopment. Goal 2 and Goal 3 addressed audience, channel, and messagesissues. The results from implementing these goals provide the necessaryframework needed to write specific communication objectives.

Communication objectives are short written statements that indicatethe expected change in health status, behavior, knowledge/attitude, orprocess in the intended audience as a result of the communication strategy.

Communication objectives should address the following questions:

  • What will be addressed (e.g.,, health status, behavior, knowledge,attitudes, process etc.)?
  • To what degree?
  • Over what time?
  • To what outcome?
Objective 4.1. Address key objective setting elements.

Each written objective should::

  • Be directed to a single intended audience;
  • Specify expected changes in knowledge, attitudes, and, where appropriate,the behavior of the intended audience;
  • Describe expected results;
  • Be time specific and precise; and
  • Be attainable ("actionable") over a reasonable time.
Objective 4.2. Write objectives with audience outcomes in mind.

When preparing objectives, focus on expected results rather than ondescribing activities. For example, training is a program activity. A communicationobjective should describe what the audience is expected to do or learnas a result of the training.

A well-defined communication objective should be interpreted in thesame way by everyone. If there is any misunderstanding or confusion, changethe objective to make it clear. Accordingly, an objective should not includevague or confusing words that lend themselves to a number of differentinterpretations. Instead, communication objectives should use action words.

Examples of confusing words: internalize, know, understand, appreciate,value, recognize, learn, sensitize.

Examples of action words: complete, use, try, enumerate, define,explain, design, summarize, resolve, construct, prepare, make, organize,select, compare, list.

Ask the following questions whenyou are writingyour objectives:

  • Could another person use these objectives to understand exactly what therecipient needs to do?
  • Isthere any objective on the listthat is vague or confusing? If two peoplehave different interpretations, change the objective to make it clear.
  • Does the list describe all the results that should be achieved?
  • Is thereDoes any objective on the list thatdescribes an activity insteadof a result?
Communication objectives serve as a blue print for program development,implementation, and evaluation. If they are not clear and "actionable,"the communication program will be unfocused, unclear, and ultimately unsuccessful.

Objective 4.3. Write communication objectives for four intendedaudiences.

The health communicator must address four important intended audienceswhen writing communication objectives, as follows:

  • Individual (primary audience)
  • Networks (primary or secondary audience)
  • Organizations (including legislative and media)
  • Media (radio, TV, written press)
Individual: The most important health-related communication outcomesat the individual level are generally health behaviors, physical actions,health access, and health status. The important outcomes (particularlyduring training and pre-deployment stages) are antecedents of health behavior,including awareness, knowledge, attitudes, self-efficacy, and skills forbehavior change.

Networks: Social networks have a profound impact on health communicationmessages and strategies. Health risk communicators should seek to influencethe information flow (two way) in a social group. Influential persons (e.g.,spouse, family members, health providers etc.) often provide entry intosocial networks.

Organizations: Organizational settings include work sites, trainingvenues, health care facilities, private advocacy organizations, and veteransgroups. The use of organizations as channels to deliver and receive healthinformation allows risk communicators to better tailor messages, reachpriority audiences with internal channels, and multiply efforts by usingexisting organizational resources. Gatekeepers often provide entry to theseorganizations.

Media: Mediainfluences shape the health message. Theyincreaseaffect the importance intended audiences attach to an issue by increasingmass media coverage, discussions by politicians and scientists, and byagenda setting. The health communicator must develop links to the mediaearly in the communication process and, where appropriate, develop clear,unambiguous theme lines concerning health risks.

The communicator should develop communication objectives for each ofthese four audiences. As individuals become concerned about an issue throughindividual or media channels, theywill likely are likely to discuss itin their social networks or organizations.

Implementation Strategies

Strategy 1. Develop a case study- based "style manual" forwriting communication objectives in the training, pre-deployment, deployment,and post-deployment stages.

Strategy 2. Provide guidelines for writing communication objectivesfor all intended audiences, including but not limited to: service members,veterans, spouses, family members, health providers, veterans groups, media,public affairs personnel, and field staff.

Strategy 3. Train field personnel in writing useful communicationobjectives.

Strategy 4. Provide a quick response system to add, modify, oreliminate communication objectives in each operation phase.

Strategy 5. Develop an interagency system that links researchprotocols, findings, and surveillance activities with communication objectives.
 Goal 5: Develop a written implementationand monitoring plan.

Implementation refers here to the act of converting communicationobjectives into actions through detailed knowledge of administration requirements,available resources, and organizational policies and procedures. Monitoringis the process of tracking the program through all phases of the healthrisk communication process and using tracking data to improve program performance.

The selection of communication objectives, messages, channels, and strategieswasis based on consideration of available resources. The main purpose of implementationis to assess those resources, match resources to communication methodsand strategies, and budget human and material resources. Monitoring providesa mechanism to identify flaws or oversights before they become major impedimentsto success and to provide a solid database for claiming success.

Objective 5.1. Develop a written assessment of resources needed.

Assess the resources required by the proposed communication intervention.This requires an examination of the time frames needed for accomplishmentof the written objectives and of the type and numbers of people neededto carry out the program.

Objective 5.2. Develop a written assessment of available resources.

Goals 1-4 of the strategic planning process identifyied objectives,strategies and materials in support of written communication objectives.Such materials might need to be developed from scratch, while in some casesexisting materials and delivery mechanisms may be available to your unit.However, such materials and mechanisms may not be tailored to the intendedaudience. Such tradeoffs will arise throughout implementation. If the communicationplan requires more personnel than the sponsoring unit has available, thenyouone may need to budget for additional costs, or reduce the cost of youractivity.

Objective 5.3. Develop a written assessment of regulations andoperating policy.

Beforeyour the communication plan can be implemented, determine whetherit is consistent with existing policy, regulation, and organization. Thecommunicator must show how the health risk communication plan serves theoverall legislative mandate, organizational mission, and operating policyof the organization.

Objective 5.4. Develop a written promotion plan.

The fully developed communication program should be introduced and promotedto the intended audiences. Promotion and distribution begin through disseminationactivities for all channels. Before the program starts, one should askthe following questions:

  • Do you haveIs there a media plan (if appropriate) for each phase ofyourthe communication plan?
  • Does every network and organization that should be involved know aboutyourthe program?
  • How preparedyour is the sstaff and others to respond to inquiries?
  • Are all supporting materials in place?
  • Are all intended audiences aware of the new program and supportive of it?
  • Do you haveAre there mechanisms in place to track progress and identifysuccesses and problems?
Objective 5.5. Develop a written monitoring plan.

Monitoring the program, through all phases of implementation, providesa mechanism to identify flaws or oversights before they become major impedimentsto success. and a Monitoring also provides solid database for claimingsuccess. A periodic review of planned tasks and time schedules will helpyouone anticipate the need to alter any plans that might be affected by unexpectedevents or delays. Anticipate altering plans to fit the situation.

The discovery of problems and flaws inyour the communication strategyreflectsthe vitality of your program because it provides the opportunity to correctproblems in time to avoid serious damage. Monitoring allowsyou one to correctthe problems and to adapt constantly to changing situations and the emergingneeds of the intended audience.

Objective 5.6. Decide on the purposes of monitoring.

Consider the following monitoring purposes:

  • To reveal what inyour the strategy is working (and not working) as expected;
  • To indicate what links toyour the intended audience are appropriate forreceiving feedback and input;
  • To permit modification of the health risk communication strategic plan;and
  • To allow an ongoing review of project outcomes.
Objective 5.5. Decide strategies for tracking.

Consider the following strategies in developingyour the tracking system:

  • Provide computer or manual services for intended audience feedback;
  • Identify and train organizations and network leaders in becoming involvedin tracking;
  • Follow up with sampling of participants to assure continued involvement;and
  • Develop a regular system of involvement and rewards for key partners.
Objective 5.7. Decide what to monitor.

Consider the following:

  • Distribution of materials;
  • Media activities;
  • Feedback on implementation strategies;
  • Identifying new, unexpected barriers;
  • Identifying the need for additional or different messages and channels;
  • Identifying the need for new or different audiences; and
  • Comparisons of the costs of materials and methods.
Objective 5.8. Select appropriate monitoring methods.

Monitoring is done in many ways using multiple forms of follow- up.Among the most common methods of monitoring are the following:

  • Regular audits of materials, messages, and channels at the point of disseminationincluding audience feedback;
  • Reviewing Internet Web traffic and media audits to identify which messagesare having impact and which need to be reinforced or refined;
  • Utilizing focus groups and intercept interviews to receive intended audiencefeedback on appropriate channels, message impact, usefulness, and satisfaction;
  • Developing key indicators (e.g., Aan increase in screening visits by theintended audience); and
  • Recording in-depth observations at dissemination points (e.g., Ttown hallmeetings, Internet use), using written protocols.
Implementation Strategies Strategy 1. Develop guidelines to secure and manage interagencyresources needed for effective health risk communication implementationand monitoring.

Strategy 2. Develop a written assessment of requirements andneeds to assure complimentary implementation of communication programswithin current agency regulations and operating policy.

Strategy 3. Develop guidelines that encourage a problem solvingor veterans need- based approach to the development of communication promotionplans for key communication activities.

Strategy 4. Develop an integrated project monitoring plan toimprove the coordination of interagency program tracking.

Strategy 5. Develop a "how to" tracking manual and provide necessarytraining for headquarters and administrative personnel on key indicatorsand measures of communication project management.

Strategy 6. Develop an electronic information clearinghouse todisseminate tracking information.

Strategy 7. Create and maintain a centralized tracking systemin the form of an electronic databaseto that may be queried for the statusof particular research reports, interim reports, and findings.

Strategy 8. Create and maintain an automated FAXfax and, phonesystem, andworld wide a website (with an appropriate graphical user interface)which allows individuals to immediately download backgroundsupporting sciencedocuments.

Strategy 9. Identify, train, and support key network and organizationalleaders to assist in program tracking.
 Goal 6. Assess effectiveness.

Goal 5 of the strategic planning process developed and implemented amonitoring system. In this final step, you will focus on ways to carryout an evaluation. Evaluation of your health risk communication interventionshould build on data collected in monitoring, which will enrich your understandingof the project for reporting purposes, changes, revisions, or expansions.

Evaluation is a purposeful effort to determine the effectivenessof the health risk communication activity.

Evaluation is essential because it provides feedback about whether theintended audience received, understood, and internalized the risk messages.Furthermore, cCommunicators cannot choose the most effective messages andstrategies without evaluation. Therefore, evaluation affects both the qualityof the communication intervention and the primary goal: improving and protectingthe health of the primary intended audience. In addition, evaluation resultsare valuable for other uses:

  • Identify success and justify a particular strategy;
  • Provide evidence of need for additional resources;
  • Increase understanding of and support for health risk communication activities;and
  • Avoid making the same mistakes in future efforts.
Objective 6.1. Decide what questions the evaluation will answer.

Consider the following:

  • Did the intended audience make the expected change?
  • How, when, and with which audiences did the changes occur?
  • What aspects of the communication contributed to these changes?
  • What aspects of the communication should be changed?
  • How cost-effective was the communication activity?
  • What lessons were learned?
Objective 6.2. Select the evaluation approach.

Process and other descriptive evaluations document what and howevents occurred. Impact (or outcome) evaluations measurewhat changes occurred and the extent to which they can be attributed tothe communication intervention.

The Table below shows the questions these two approaches answer andthe best time to collect data during the intervention.

Type Of Evaluation
Critical Questions
Data Collection
Process evaluation Is the communication strategy performingto expected standards? Throughout the program.
Impact Evaluation

Short Term

Long Term

  • Are health behaviors changing? If so, to what extent?
  • Did the intended audience's health status improve?
  • Was the health risk communication program effective?
  • At important transition points, and at the end 
  • At important transition points, and at the end
  • At end of program


Objective 6.3. Decide what questions the process evaluation willanswer.

Process evaluation describes the implementation of the health risk communicationprocess and demonstrates the efficiency of the program implementation.It answers the following general questions:

  • What happened during the implementation?
  • How was each goal carried out or not carried out?
  • Were activities consistent with the overall strategic plan?
Objective 6.4. Select a technique to do the process evaluation.

Several process evaluation techniques can be applied in different waysand for different purposes as follows:

  • Observation of individual or group behavior, incidents, or activities.These observations should follow written interview guidelines.
  • Individual interviews using open-ended questions, revealing informationon what happened during implementation.
  • Record review, interpretation, and analysis of documents (e.g., activityreports, minutes, meeting summaries, etc...), revealing what happened duringimplementation.
Objective 6.5. Select a techniqueto do for doing the impact evaluation.

Usually, in the case of communication activities, impact evaluationsfocus on the behavioral changes defined by the communication objectives.Data from impact evaluations will help you determine if and to what extentthe intended audience assimilated the expected knowledge, and changed theirattitudes andtheir its level of action;, fFor example,was there an increaseddid use of health facilities for screening purposes increase?

Impact evaluations compare one group both before and after the interventionor compare a group that did not benefit from the program with a group thatdid. A relatively simple method of comparison is to use time series charts,in which data for a given group, organization, or individual are enteredin a time chart. For example, chart the numbers of weekly screening visitsto selected clinics by veterans before and after the communication intervention(e.g., a major media campaign).

Objective 6.6. Design an evaluation plan with written evaluationobjectives.

The following four steps will guide you in designing an evaluation planfor youthe communication activity:

Step 1: Establish Evaluation Objectives and Indicators. It isnecessary to establish the objectives of your evaluation. They are differentfrom your communication strategy objectives, but will be linked to them.They are indicators of expected changes in knowledge, practices, or healthstatus as the result of your intervention. The following questions willhelp you develop a list of evaluation objectives:

  • Why are we conducting this evaluation?
  • What do we hope to measure or demonstrate?
  • Who is our audience for the evaluation findings?
  • Who will use the findings?
  • What decisions will be based on these findings?
Step 2: Determine a Research Design. The design should respond tothe evaluation objectives. you selected.

Step 3: Analyze Evaluation Results. Analyze the evaluation resultsbased on the key findings, communication objectives, adoption of feasiblebehaviors, change in knowledge and attitudes, and affect on health status.

Step 4: Make Use of Your Evaluation Data. Use the evaluationresults to consider different strategies for the next phase of the healthcommunication program, improve the program, and develop new implementationstrategies and direction.

Implementation Strategies

Strategy 1. Develop an "easy- tto- read" (and implement) field-testedevaluation manual to improve the effectiveness of health communicationmessages and strategies.

Strategy 2. Train field personnel on the application of communicationevaluation techniques and "tools"."

Strategy 3. Identify and select a list of peer evaluation counselorsincluding veterans and service personnel to advise DoD and VA on evaluationstrategies and programs.

Strategy 4. Disseminate the results of interagency evaluationefforts to include peer-reviewed literature, conferences, and workshops.

Strategy 5. Maintain an easily accessible electronic clearinghouseof evaluation efforts.

Strategy 6. Develop and support a fFederal health risk communicationresearch program to investigate and recommend improved health risk communicationtechniques and outcome measures, specifically intended for military personneland their families.

Appendix B

PRD/NSTC-5Interagency Working Group and Task Forces

Interagency Working Group Members


Departmentof Defense

Mr. Gary Christopherson (Co-Chair, Deployment Health)

Office of the Assistant Secretary for Health Affairs

RADM Michael Cowan, MC, USN (Co-Chair, Deployment Health)

The Joint Staff

Mr. James Reardon (Co-Chair, Record Keeping)

Office of the Assistant Secretary for Health Affairs

Ms. Norma St. Claire (Co-Chair, Record Keeping)

Office of the Under Secretary for Personnel and Readiness

Departmentof Veterans Affairs

Mr. Michael Baker (Co-Chair, Record Keeping)

Office of the Under Secretary for Benefits

Dr. Timothy Gerrity (Chair, Research)

Research and Development Office

Dr. Frances Murphy

Public Health and Environmental Hazards

Departmentof Health and Human Services

LCDR Drue Barrett

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

CAPT G. Bryan Jones

Office of the Secretary

Dr. Max Lum

Centers for Disease Control and Prevention/National Institute of OccupationalSafety and Health

CAPT Peter P. Mazzella, Jr.

Office of the Secretary

LCDR Patrick McNeilly

Office of the Secretary

Mr. Christopher Olenec

Centers for Disease Control and Prevention/National Institute for OccupationalSafety and Health

Dr. Christopher Schonwalder (Chair, Health Risk Communications)

National Institutes of Health/National Institute for Environmental HealthSciences

ExecutiveOffice of the President

RADM Paul Busick, USCG

National Security Council

Dr. Clifford Gabriel (Chair, IWG)

Office of Science and Technology Policy

Dr. Gregory Henry

Office of Management and Budget

CRD Philip Heyl, USCG

National Institute of Environmental Health SciencesCDR Phillip Heyl,USCG

National Security Council

Dr. Carolyn Huntoon

Office of Science and Technology Policy

Ms. Alexandra Lehr

Office of Management and Budget

Ms. Suzanne White

Office of Management and Budget

DeploymentHealth Task Force Members


Departmentof Defense

Lt ColLTCLtCol David V. Adams, NC, USAF

The Joint Staff

Mr. Gary Christopherson, (Co-Chair)

Office of the Assistant Secretary for Health Affairs

RADM Michael Cowan, MC, USN (Co-Chair)

The Joint Staff

CAPT David Trump, MC, USN

Office of the Assistant Secretary for Health Affairs

LTG Dale Vesser, USA (Retired)

Office of the Special Assistant for Gulf War Illnesses

Departmentof Health and Human Services

CDR Peter Delany

National Institutes of Health/National Institute on Drug Abuse

CAPT Brian Flynn

Substance Abuse and Mental Health Services Administration/Center forMental Health Services

CAPT G. Bryan Jones

Office of the Secretary

Dr. Louis Mahoney

Health Resources and Services Administration

Dr. William Reeves

Centers for Disease Control and Prevention/National Center for InfectiousDiseases

CAPT William Robinson

Health Resources and Services Administration

CAPT David Snyder

Health Resources and Services Administration

CAPT Armen Thoumaian

Health Care Financing Administration/

CDR Kevin Tonat/Office of the Secretary

CAPT Armen Thoumaian

Health Care Financing Administration

Departmentof Veterans Affairs

Dr. Timothy Gerrity

Research and Development Office

Dr. Susan Mather

Public Health and Environmental Hazards

Dr. Timothy Gerrity

Research and Development Office

Dr. Frances Murphy

Public Health and Environmental Hazards

RecordKeeping Task Force Members


Departmentof Veterans Affairs

Mr. Michael Baker (Co-Chair)

Under Secretary for Benefits

Departmentof Defense

Ms. Norma St. Claire (Co-Chair)

Office of the Under Secretary for Personnel and Readiness

Ms. Pat Collins

Office of the Assistant Secretary for Health Affairs

Ms. Marty Hamed

Office of the Under Secretary for Personnel and Readiness

Ms. Bette Mahoney

Office of the Under Secretary for Personnel and Readiness

LtCol Mary Ann Morreale

Office of the Assistant Secretary for Health Affairs

Ms. Nancy Orvis

Office of the Assistant Secretary for Health Affairs

Mr. James Reardon (Co-Chair)

Office of the Assistant Secretary for Health Affairs

Departmentof Health and Human Services

Mr. Brian Malkin

Food and Drug Administration

ResearchTask Force Members


Departmentof Veterans Affairs

Dr. Matthew Friedman

National Center for Post-Traumatic Stress Disorder

Dr. J. Michael Gaziano

VA Medical Center, West Roxbury

Dr. Timothy R. Gerrity (Chair)

Office of Research and Development

Dr. Matthew Friedman

National Center for Post-Traumatic Stress Disorder

Dr. J. Michael Gaziano

VA Medical Center, West Roxbury

Dr. Han Kang

Public Health and Environmental Hazards

Dr. Frances Murphy

Public Health and Environmental Hazards

Dr. Roberta F. White

VA Medical Center, Boston

Departmentof Defense

Ms. Christine Eisemann

Office of the Director, Defense Research and Engineering

LTC Charles Engel, MC, USA

Uniformed Services University of the Health Sciences

Ms. Christine Eisemann

Dr. John M. Ferriter

Col Gary Gackstetter, BSC, USAF

Uniformed Services University of the Health Sciences

Dr. Jack M. Heller

U.S. Army Center for Health Promotion and Preventive Medicine

CAPT K. Craig Hyams, MC, USN

Naval Medical Research Institute

Dr. Anna Johnson-Winegar

Office of the Director, Defense Research and Engineering

Lt ColLTCLtCol James Riddle, BSC, USAF

Office of the Assistant Secretary for Health Affairs

LTC James Romano, MSC, USA

U.S. Army Medical Research and Materiel Command

CAPT Steven Torrey, MC, USN

Office of the Special Assistant for Gulf War Illnesses

CAPT David Trump, MC, USN

Office of the Assistant Secretary for Health Affairs

Departmentof Health and Human Services

CAPT Michael Alavanja

National Institutes of Health/National Cancer Institute

LCDR Drue Barrett

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

CAPT Glen Drew

Food and Drug Administration

CAPT Bryan Hardin

Centers for Disease Control and Prevention

CAPT G. Bryan Jones

Office of the Secretary

Mr. Brian Malkin

Food and Drug Administration

Dr. Sheila Newton

National Institutes of Health/National Institute for Environmental HealthSciences

EnvironmentalProtection Agency

Dr. Andrew Bond

Office of Research and Development

Persian GulfVeterans Coordinating Board

CDR David Edman, MSC, USN

HealthRisk Communications Task Force


Departmentof Health and Human Services

LCDR Drue Barrett

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

Dr. Mary Jo Deering

Office of the Secretary

Ms. Gail Hayes

Centers for Disease Control and Prevention/Office of Public Affairs

CAPT Bryan Jones

Office of Military Liaison and Veterans Affairs/Office of the Secretary

Dr. Max Lum

Centers for Disease Control and Prevention/National Institute for OccupationalSafety and Health

Mr. Jim Mathews

Office of the Secretary

Mr. Christopher Olenec

Centers for Disease Control and Prevention/National Institute for OccupationalSafety and Health

Dr. Christopher Schonwalder (Chair)

National Institutes of Health/National Institute for Environmental HealthSciences

Mr. Christopher Olenec

Centers for Disease Control and Prevention/National Institute for OccupationalSafety and Health

Mr. Jim Mathews

Office of the Secretary

CAPT Bryan Jones - Director, Office of Military Liaison and VeteransAffairs

Office of the Secretary

Dr. Mary Jo Deering

Office of the Secretary

Dr. Max Lum

Centers for Disease Control and Prevention/National Institute for OccupationalSafety and Health

Ms. Diana Swindel

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

Mr. Phil Talboy

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

Dr. Tim Tinker

Centers for Disease Control and Prevention/Agency for Toxic Substancesand Disease Registry

LCDR Drue Barrett

Centers for Disease Control and Prevention/National Center for EnvironmentalHealth

Departmentof Defense

Dr. Kelley Brix

Office of the Special Assistant for Gulf War Illnesses/SRA International

Ms. Pat Collins

Office of the Assistant Secretary for Health Affairs

MAJ Andrea Crunkhorn, MSC, USA

Office of the Assistant Surgeon General for Force Projection, U.S. Army

BG John Parker, MC, USA

Office of the Surgeon General, U.S. Army

MAJ Andrea Crunkhorn, MSC, USA

Office of the Assistant Surgeon General for Force Projection, U.S. Army

Ms. Pat Collins

Office of the Assistant Secretary for Health Affairs

Dr. Kelley Brix

Office of the Special Assistant for Gulf War Illnesses/SRA International

Departmentof Veterans Affairs

Dr. Timothy Gerrity

Office of Research and Development

Ms. Kathy Jurado

Public and Intergovernmental Affairs

Dr. Timothy Gerrity

Office of Research and Development

Mr. John Kraemer

Public Health and Environmental Hazards

Dr. Frances Murphy

Public Health and Environmental Hazards

Mr. Donald J. Rosenbloom

Public Health and Environmental Hazards

Mr. John Kraemer

Public Health and Environmental Hazards

ExecutiveOffice of the President

CAPT Philip HyelCDR Phillip Heyl

National Security Council

Persian GulfVeterans Coordinating Board

CDR David Edman, MSC, USN

Interagency Support Office

EnvironmentalProtection Agency

Dr. Frederick Allen

Office of Strategic Planning and Environmental Data

CAPT Alvin Chun

Air and Toxics Division

Mr. Ken Stroech

Deputy Emergency Coordinator

CAPT Alvin Chun

Air and Toxics Division

Appendix C

Establishmentof NSTC/PRD-5

Development of Interagency Plans to Address Health Preparednessfor and Readjustment of Veterans and Their Families After Future DeploymentsPresident Clinton established the Presidential Advisory Committee on GulfWar Veterans= Illnesseson May 26, 1995, to ensure an independent, open and comprehensive examinationof health concerns related to Gulf War service. The Committee issued itsfinal report on December 31, 1996, documenting its review of the government=soutreach, medical care, research, efforts to protect against and to assessexposure to chemical and biological weapons, and coordination activitiespertinent to Gulf War veterans=illnesses. During the course of the Committee=sdeliberations, government efforts to address and to resolve veterans=concerns continued, consistent with respective agencies=missions to provide for the health and welfare of active, reserve, andretired service personnel and their dependents. The issuance of the Committee=srecommendations provides valuable guidance to the Federal gGovernment inreviewing policies and programs and developing a coordinated, interagencyplan for minimizing or preventing similar post-conflict health concernsin the future, to the extent possible.

Extensive public review and analysis of Gulf War veterans=illnesses and risk factors have identified a number of opportunities forgovernment action aimed at minimizing or preventing future post-conflicthealth concerns. Ameliorating, avoiding or, ideally, preventing such healtheffects can be approached through a variety of means. These include improvingservice personnel=s understandingof health risk information; enhancing government collection of health andexposure data; coordinating agency research programs; and improving thedelivery of health care services to veterans and their families, as couldbe accomplished by establishing effective linkages between health informationsystems.

The Presidential Advisory Committee on Gulf War Veterans=Illnesses recommended that the National Science and Technology Council(NSTC) Adevelop an interagencyplan to address health preparedness for and readjustment of veterans andfamilies after future conflicts and peacekeeping missions.@This directive responds to the Committee=srecommendation. The agencies identified above, and others as appropriate,are asked to review policies and programs and identify relevant actionsthat may be taken by the Federal gGovernment to better safeguard thoseindividuals who risk their lives to defend our Nation=sinterests. Agency recommendations will be reviewed, programs will be coordinated,and the result will be integrated into an NSTC report. In accordance withthe Advisory Committee=sproposal, the NSTC report will be submitted for outside expert review.

Agency Rrecommendations are expected to address:

C Health (e.g., stress prevention,treatment, research; medical surveillance adequacy, coordination; interventionsfor families);

C Outreach and health risk communication;

C Record keeping (e.g., accountability,timeliness, cross-agency coordination, application of new technologies);

C Research (e.g., adequacy, quality,coordination, dissemination of results);

C Biological and chemical weaponspreparedness and research;

C Application of emerging technologies(e.g., telemedicine, technology transfer); and

C International cooperation andcoordination, especially on research and technology matters.It is crucial that the lessons from the Gulf War experience be appliedin improving protection of troops, responding to health concerns and assistingveterans and their family members through difficult transitions. A comprehensive,coordinated set of interagency plans is necessary to build upon what wehave learned and ensure that the burden borne by those who risk their livesand well-being to protect our country's interests is minimized.

Assessment Contexts

These recommendations should be accommodated within and among the restof the agency's budget priorities. Each agency must report on how it intendsto accomplish these programs and policies within its budgetary allowances,subject to its resource constraints.


The report should be completed and approved by the NSTC by April 21,1998.At that time, it will be submitted to the President=sCommittee of Advisors on Science and Technology (PCAST) and other nationalexperts for review and comment. This process is expected to take approximately3 months. Another 3 months are allocated for analysis and revision of theplan, after which it will be resubmitted to NSTC.

External Advice

The NSTC may seek advice, in accordance with existing laws, from membersof the PCAST, National Academy of Sciences, Institute of Medicine, andother appropriate representatives of industry, academia, the non-profitprivate sector, and state governments in preparing the report.


Agencies shall provide the NSTC with the administrative resources neededfor agency review and preparation of the NSTC's report.

Appendix D

Listof Abbreviations


Agency for Toxic substances and Disease Registry (ATSDR)

Centralized Credentials Quality Assurance System (CCQAS)

Chemical and biological weapons (CBW)

Chemical, Biological, and Radiological Warfare Agents (CBR)

Commanders in Chief (CINC)

Composite Health Care System (CHCS)

Defense Personnel Records Imaging System (DPRIS)

Defense Enrollment Eligibility Reporting System (DEERS)

Defense Personnel Data Model (DPDM)

Defense Casualty Information Processing system (DCIPS)

Defense Integrated Military Human Resources System (DIMHRS)

Department of Veterans Affairs (VA)

Department of Health and Human Services (DHHS)

Department of Defense (DoD)

Environmental Protection Agency (EPA)

Food and Drug Administration (FDA)

Global Command and Control System (GCCS)

Global Combat Support System (GCSS)

Gulf War Illnesses (GWI)

Health Enrollment Appraisal Review (HEAR)

Information technology (IT)

Information management (IM)

Interagency Working Group (IWG)

Joint Disability Evaluation Tracking system (JDETS)

Joint Personnel Asset Visibility (JPAV)

Joint Integration Group (JIG)

Master Patient Index (MPI)

Military Personnel Policy Review Committee (PRC)

Military and Veterans Health Coordinating Board (MVHCB)

Military Health System (MHS)

National Archives and Records Administration (NARA)

National Research Council (NRC)

National Institute for Occupational Safety and health (NIOSH)

National Science and Technology Council (NTSC)

National Academy of Sciences (NAS)

Office of Science and Technology Policy (OSTP)

Office of the Assistant Secretary of Defense for Health Affairs (OASD(HA))

Office of the Secretary of Defense (OSD)

Patient Administration Real-time Reporting and Tracking System (PARRTS)

Personal Information Carrier (PIC)

Personnel and Readiness (P&R)

Presidential Advisory Committee (PAC)

Presidential Review Directive (PRD)

Preventive Health Care System (PHCS)

Social Security Number (SSN)

Transportation Command Regulating and Command and Control and EvacuationSystem


Under Secretary of Defense (USD)

Under Secretary of Defense Personnel and Readiness (USD (P&R))

Unit Identification Code (UIC)

Office of Scienceand Technology Policy
1600 Pennsylvania Ave, N.W
Washington, DC 20502

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