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Force Health Protection Briefing

Presenter: Assistant Secretary of Defense Health Affairs William Winkenwerder
March 13, 2003 11:30 AM EDT

(Briefing on Force Health Protection. Also Participating: Deputy Assistant to the Secretary of Defense Chem/Bio Anna Johnson-Winegar; Deputy Assistant to the Secretary of Defense Force Health Protection & Medical Readiness Ellen Embrey; U.S. Army Surgeon General Lt. Gen. James Peake; Joint Staff Senior Medical Officer Adm. John Mateczun; Air Force Surgeon General Lt. Gen. George P. Taylor; Navy Surgeon General Vice Adm. Michael Cowan; and Department of Veterans Affairs Deputy Under Secretary for Health Jonathan Perlin.)

Slides shown during this briefing can be found on the Web at: http://www.defenselink.mil/news/Mar2003/g030313-D-9085M.html

Staff: Okay, over the past few weeks, there have been a growing interest in health care for our deploying service members. Today, we have a panel of experts, led by Assistant Secretary of Defense William Winkenwerder, to walk you through the important issue of force health protection. Dr. Winkenwerder will begin with a few remarks and then we'll introduce the experts who make this system work. After they have all concluded their remarks, questions will be taken. This briefing is on the record. We will have a list of the speakers available after the briefing and handouts in the back.

Dr. Winkenwerder.

Winkenwerder: Thanks, Jim.

And good morning. Thank you for coming. We appreciate your being here.

Protecting the health of our forces is my top priority as the Assistant Secretary of Defense for Health Affairs. It is also true for every person who will be -- who is gathered with me here today. And I look forward to their time with you sharing what we do.

Force health protection is a continuum of programs to maintain health and to provide multiple layers of protection to service members. Our program is more than about what we are doing right now, today. It's about the totality of what we do to protect service members and their families throughout their whole time and their whole career in the military service.

When we talk about force health protection, we mean three broad areas. The first of those is fitness and health, protection and prevention, and then care and treatment.

Fitness and health -- let me talk about that for a minute. We have an important job to maintain the fitness and health of all of our service members. Our work begins even before service members come on to active duty with some very rigorous requirements of entrance physicals. And then once on active duty, our service members must maintain their health through annual fitness testing, regular medical and dental exams, health promotion activities, personal health assessments and routine screening exams for things like HIV.

Second, protection and prevention. We often speak about layers of protection, and here is what we mean when we talk about that. We mean that we bring an array of medical technologies and capabilities to protect service members. Our protection is not just sort of one line of defense. First, vaccines. As you know, we have resumed the anthrax and smallpox vaccine programs for our service members in high-threat areas. We have protected them against these threats. Both programs are going very well, and they are examples, in my judgment, for our civilian sector.

We also administer many other vaccines to our service members based on where they're assigned, their job duties, where they might deploy, and what threats exist in those areas. Vaccinations are an important part of our overall layer of protection -- layers of protection.

Medical equipment. Our people have the best equipment to protect them from biological and chemical threats of any fighting force in the world. There should be no doubt about that. There's individual protection, suits, masks, boots. There's also collective protection. In that particular area, there are many new capabilities, actually, as well in the individual protection area.

But there are other elements. Chemical and biological detection systems to alert us if an agent is in the environment; medical surveillance systems that provides near-real-time, theater-wide information on environmental hazards; medical treatment information and medical logistics information. And that means things like blood supply, the supply of antibiotics, and equipment. Dr. Anna Johnson-Winegar, in particular, who is with me today, will talk more about our medical equipment protection capabilities.

Finally, deployment health practices and procedures. We take many steps to protect people who deploy, and this includes a pre- deployment health assessment before people deploy, continuous hazard and health monitoring in the field, and then after they deploy, a post-deployment assessment.

The third element of our overall force protection -- force health protection strategy and doctrine is treatment and care. When a service member is ill or injured in battle or at home, our responsibility is to restore that person's health.

When we deploy our forces, we bring a formidable medical capability -- far forward surgical care; medical evacuation assets, to include the ability to provide intensive care in the air; and ship-based medical capabilities. In the event of a biological or chemical attack, we also maintain significant decontamination equipment and the ability to treat both chemical and biological casualties.

This is a summary view of our medical capabilities that we bring to our service members. It's a very important capability. It's even more impressive when you view it up close and in its totality. But our most important asset in all this is our people, our medical professionals. They're superbly trained to do their job and to save lives.

Now, I know much has been talked about this issue and what have we learned since the Gulf War. And I would just say to you that much has been accomplished; we have learned many lessons over the past decade. Our level of effort and our capability to protect our forces is unprecedented in military history, particularly compared with our adversaries, but even with our allies. However, as we all know, today we face new and deadly threats and the possibility that a brutal regime would use chemical or biological weapons. As military professionals and as health professionals, we're well aware that war involves real risks, and that's particularly true in today's situation.

But our message to you, to our service members, to their families, and to the American people is that we are prepared and we will take extraordinary measures to protect and care for people, should we be called to do so.

Now, at this time I'd like to introduce my deputy for force health protection, Ellen Embrey; and Dr. Anna Johnson-Winegar, who is the assistant -- I'm sorry, the deputy to the assistant to the Secretary of Defense for Chemical and Biological Programs; and Vice Admiral -- Rear Admiral John Mateczun, who is the senior advisor -- medical advisor and chief medical advisor to Chairman Myers.

And with that, I'll let you guys take over from here.

Embrey: Thank you, Dr. Winkenwerder. I appreciate that kind introduction.

I am Dr. Winkenwerder's deputy for Force Health Protection and Readiness. It is my responsibility to make sure that the policies that are being developed within the department to do this --

Q: Could you give us your name again and spell it before you --

Embrey: Sure. I believe that's going to be provided at the end, but I'll be happy to do that now. It's Ellen Embrey, E-M-B-R-E-Y. I'm his deputy for Force Health Protection and Readiness.

I daily work with the colleagues here at this table, as well as the surgeons from each of the services, as well as with partners at HHS, VA, and the Department of Homeland Defense, to make sure that our force health protection policies are well integrated across the capability of this great nation.

I think it's important to know that my main job is coordination, facilitation of improved policies, and evaluation, to make sure that those improvements are accomplished in a timely basis.

I have a short time to talk because there's many on this agenda. I'm going to highlight a few of the things that we've accomplished recently, mostly derived from what we've learned in operations over the last decade.

First, I want to elaborate briefly on the pre- and post- deployment health assessments that Dr. Winkenwerder alluded to. They are our tool for validating individual medical readiness through the continuum to address health concerns before, during and after their deployments.

We also have established individual serum repositories - individual serum specimens that are maintained in the DOD serum repository. We also have improved occupational and environmental health surveillance programs that help protect our service members' health during deployments.

A second highlight would be the implementation of an interim theater medical information system. It's a very comprehensive system that allows us to capture for the first time theater-wide information about medical encounters of deployed forces. It also allows us to capture data about the disease and non-battle injury information for those forces that will enable us to maintain good records, so that they could be maintained in their permanent records, and it will also allow us to detect things that were not otherwise detected -- the health effects of an undetected biological/chemical attack -- and to have a fairly effective response to that as quickly as possible.

We have a demonstration of that system at the end of this, and I encourage you to look at it. It's a very good system. It is an interim system, and it reflects a capability that we're developing in the long term that will be even more robust.

Lastly, I'd like to talk about three deployment health centers that have been established within the department, one to focus on health surveillance, one to focus on health care and one to focus on health research, all with an eye towards the prevention, treatment and understanding of deployment health concerns. Each of them have been very effective in providing us with good information on how to be responsive to the deployment issues that confront our service members. We developed a post-deployment health clinical practice guideline with the Department of Veterans Affairs to ensure that the medical providers in our force and in VA provide effective and appropriate response to the medical concerns of our deployed soldiers upon their return.

And with that, I would like to conclude my remarks and introduce Anna Johnson-Winegar. She is the deputy assistant to the Secretary of Defense for Chem-Bio Defense.

Johnson-Winegar: Thank you, Ellen, and good morning to everyone. I'm very pleased to be here this morning to provide just a few remarks about our chemical-biological defense program. And I've brought with me a number of different show-and-tell items. And I'll be happy to talk with you in more detail afterward about those. And in addition I'll be using some posterboards as I go through my presentation, and I'll call your attention to them as we talk about the specific areas.

First of all, let me say that I believe that our forces do, indeed, have the best equipment that is available. It is world class. It is unsurpassed. And they are prepared to defend against a chemical and biological attack. Part of our program is the medical program, which is the emphasis of today's discussion. However, an equally important part is what we call the non-medical program, and that's what I want to highlight for you in just the few minutes that I have this morning.

First of all, we realize that there is no silver bullet. There's no one easy answer that can provide everything to everybody with regard to chemical and biological defense. So we've developed an integrated system that encompasses a number of different focus areas.

The first of those is contamination avoidance. Obviously, if we know where and when a chemical or biological agent is going to appear, we can avoid it. To help us do that, we have developed very modern, very specific and sensitive chemical and biological detectors. Shown on the first of these posterboards are some of the chemical agent detectors. We are currently deploying these items to the field. In addition, we have some of them here today that you can look at. And I'd be happy to answer more questions afterwards.

On the second of the charts is a pictorial representation of some of the biological detection capabilities. These are things that we have today that we did not have in the Gulf War. In particular, shown here are the Biological Integrated Detection System in the upper left. That's mounted on a Humvee vehicle. And some of the others are stationary types of biological detection systems. Again, I want to emphasize that we can now detect a broader range of biological agents with a greater degree of sensitivity and specificity than we've been able to do in the past.

On the third of the poster boards is a picture of our reconnaissance vehicle. This is able to go out and survey the surrounding terrain to be able to identify whether the landscape has been contaminated with a chemical or biological agent, thus providing very vital information to the unit commander.

Next I'd like to move just very rapidly to individual protection. Shown here is a pictorial representation of our new all-encompassing suit. It's called the JSLIST suit. That stands for Joint Service Integrated Biological Protection -- I'm sorry -- Joint Service Lightweight Integrated Suit Technology. And the individual pictured here is wearing the suit as well as the mask. Also shown are some of the items of medical equipment. We're very proud of the fact that we have again world-class equipment that can be used either to treat in advance or to treat post-exposure a chemical or biological casualty.

The improvements that the suit brings are that it's lighter- weight, it's launderable, and it lasts for a longer period of time. We've made extraordinary efforts to increase the production of our suits from 79,000 to over 90,000 suits per month since December, and we currently have sufficient capability to provide a minimum of two and will soon reach a minimum of three suits per individual that are deployed in theater.

Shown here are our collective protection shelters. These are indeed a very valuable capability for those units that tend to stay in one period (sic) for a long period of time. We are currently procuring additional collective protection systems for our medical units. Specifically shown here are the chemical/biological protective shelter and the CP DEPMEDS system. These shelters increase our capability to provide medical treatment on a contaminated battlefield.

Next, with regard to decontamination, some of the major improvements that we've made in this area are in the area of individual decontamination and decontamination for personnel equipment. Shown here is the skin decon kit which is currently fielded and uses a reactive powder sorbent type of technology, which is environmentally acceptable, non-corrosive, and can be used to decontaminate skin as well as items of personal equipment.

Beyond these typical examples of things that I've shown to you, I do want to emphasize that we continue to invest in a very strong and robust science and technology program which serves as the basis for all of these items that you see here today. We are able to leverage and benefit from the very best minds and research facilities in academia, industry and other federal agencies. And I think that our investment in these types of things has been shown to pay off, as we are currently able to field much superior equipment to what we had 10 years ago. I think that you'll agree that these highlighted improvements and measures have significantly improved our forces' ability to survive and sustain operations on a potential battlefield where chemical or biological agents might be used.

I just want to close by saying that it is very clear and very obvious to all of us that our U.S. forces deploying to the Persian Gulf have, without a doubt, the best chemical/biological defense equipment in the world. They are trained, they are ready, and we are prepared.

At this time, I'd like to turn it over to Admiral Mateczun from the Joint Staff to give a little bit of perspective from the operational point of view.


Mateczun: Thank you, Anna.

Good morning. I'm Dr. John Mateczun, the Joint Staff surgeon. In that capacity, I act as the senior physician on the Joint Staff and the medical adviser to General Myers, the chairman of the Joint Chiefs. I work on behalf of the Joint Staff and the services to work together to develop the force health protection strategy that we have.

We've worked very hard in the last five years with the Department of Defense, the Office of the Secretary, the Services and the Joint Staff to develop the strategy of force health protection. And this is a capstone document that we provided some copies for that you can look at to take a look at the strategies that we've got. I just want to emphasize that force health protection is a strategy. It's a strategy to protect our most important asset, our service members and their families. I also want to point out that the strategy is a life cycle strategy. It's not one point in time. It's not just during a deployment that we protect the service members' health. It's during their entire careers. In fact, it's before their careers start and after their careers end that the strategy goes on.

General Myers has three priorities that he asked the Joint Staff to focus on: Winning the global war on terrorism, defeating weapons of mass destruction. Secondly, enhancing joint war fighting. And thirdly, transformation. In that regard, I'd like to provide to you three critical joint successes that really qualify for all three of those and fit within the strategies of force health protection.

Number one is forward surgery. The forward surgical teams, only a dream 10 years ago during Operation Desert Storm, have now become a reality, and many of you may have encountered them or seen some of the people during Operation Enduring Freedom that were out with forward surgical teams -- takes the operating room out of the hospital, puts it into the forward environment, provides life-saving resuscitative surgery early and quickly, within that golden hour that we know we need to get to casualties to. In fact, this strategy has been so successful that of those people who have made it back to forward surgical teams, all have survived.

There's a second reason for that, and that's the number -- the second example that I'd like to give to you, and that's critical care transport. We have moved from a strategy of stable -- making people stable before we move them to being able to provide life-saving resuscitative surgery, stabilizing them and then, with critical care assets, the monitors that you would see in an intensive care unit, actually moving them out of theater. And I think that General Taylor from the Air Force, in particular, is going to tell you a little bit more about that. That's a significant change in that way that we've been able to provide this kind of care in the past.

Lastly, I'd like to just mention one example of success from our science and technology base, and that is the development of the bioassays and the materials that we need to identify biological agents by the laboratories, particularly our military laboratories and the other parts of the scientific base that we use, so that we are able to know with some certainty whether or not a biological agent has been used or is present in any given place.

And with that, Dr. Winkenwerder, I think we'd like to move to the surgeons general.

Winkenwerder: Great. If I can ask the next panel -- thank you very much. And they will be available for questions here and will be standing by.

Let me introduce Lieutenant General James Peake, surgeon general of the Army; Vice Admiral Mike Cowan, surgeon general of the Navy; and Lieutenant General Peach -- George Peach Taylor, who is the new surgeon general of the Air Force.

With that, I'll turn it over to Jim.

Peake: Because we are in the same part of the world as we were 12 years ago and because we have maybe the same enemy, some people seem to think that it is sort of the same war. It is actually different operationally, and it's different medically.

To follow on to some of the notions that you've heard, in the Army, on the forward surgical team business, we took pieces of combat support hospitals during Desert Shield/Desert Storm, pulled them out, moved them forward with the force. Since then we've developed the forward surgical team capability that have things like portable Doppler machines with them, external fixators with them, that can travel with the force. We have active and Reserve. We train at the Ryder Trauma Center at -- in Miami, so that we have that kind of experience that is refreshing to our surgeons, with their surgical capabilities.

When you talk about chem/bio protection, our collective protection during Desert Shield, Desert Storm was the tent. And, you know, that offers some protection. But the stuff that Dr. Anna Johnson-Winegar talked to you about, we have in place, in theater now; the Humvee-mounted, protective shelters that are on the back can be complexed; three of them can hold an Army forward surgical team. You can put in one with the battalion aid stations. We are using those with the Marines. In addition, the chemical -- CP DEPMED, the Chemical-Protected DEPMED, the Deployable Medical Systems, that's our hospitals, have sets that allow us to seal and filter the air, and have an environment where you can take care of the patient, continue the mission, even if you're in a chemically or biologically contaminated area.

Our soldier medic is different. About two years ago, we started a restructuring of our combat medical training. It is now -- instead of 10 weeks, it is 16 weeks. They come out EMTB, Emergency Medical Technician Basic level certification. The extra time gives them the chance to get more hands-on skills, to do those kinds of things in the field in MOPP gear as an example. And they report into their units better trained, better airway and IV management skills, and more confident in those skills as well.

From an immunization perspective, in Desert Shield/Desert Storm, we sent teams into theater to give anthrax. Many of you may remember. Now we have an anthrax program for vaccination and protection of the force that is second to none. It includes all the things that are important, like informing the patient about what kind of medicine they're getting and why. It informs the people that are providing the immunizations the right kind of information. We have a good collection effort to ensure if there's any adverse events that we collect them.

That effort and that experience in the last 12 years has informed us about what we ought to be doing with smallpox. And so we are part of the national smallpox vaccination. You know that our campaign started after the president announced his. Again, it is with patient information, provider information, and quality gathering of potential adverse events.

The environmental issues of war are always important, and we did not have -- we have the Center for Health Promotion, Preventive Medicine now that has some of this equipment that's before you, that goes out and collects, proactively, environmental soil, air, water kinds of samples, to know where to put the soldiers -- and by the way, archive the information in the lab results so that ultimately we can go back and look and decide if there are any correlations with anything we find later on. That's a proactive rather than a reactive approach now.

Speaking of archiving, we have 30 million serum samples, as Dr. -- as Ms. Embrey talked about -- stored that are tied to our HIV collection program. And every soldier and sailor and airman and Marine has those kinds of biological specimens on file so that we can go back retrospectively and look if we determine that there is any kind of issue that we need to investigate.

So, you know, I guess I would just say that it is not ODS all over again; it is -- and we are well prepared, and better prepared than we were then.

Thank you very much.

Taylor: Thanks, General Peake.

As you look back over the last 15 years, it's pretty clear that the military is used in ways that we really didn't clearly see in the Cold War. In Somalia, Bosnia, Kosovo, and even this recent operation Enduring Freedom, we're seeing a much greater use of joint and combined forces, conventional and special forces. We're blending across the traditional services. And this has caused all three of us to work very hard to identify and close any seams that may occur in patient care. We're trying to create an interlocking medical system for every soldier, sailor, airman, Marine, or Coast Guardsman.

In peacetime, we operate a robust health care system that delivers a wide range of care to our beneficiaries -- active duty, family members, retirees, and their families. This provides a sound deployment platform for our troops and for our medics. At home, our airmen undergo constant health care evaluations, from occupational health exams, to routine health activities, to periodic planned assessments. All of these are built to ensure that we have the most fit and healthy airmen and that we keep them that way.

That said, the Air Force medical service must transition from a peacetime health care system to a robust combat system. Our concept of operations has actually changed over the last decade. We now deploy medical assets in modules tailored for the mission, whether it's a three-person, with backpacks like this, to field hospitals, as you see in the slide over here, with over a hundred personnel.

A major transformation has occurred. It's in our Air Medical Evacuation System, as Dr. Winkenwerder mentioned. By placing our assets further forward and employing critical care air transport teams, we gain a crucial advantage over time by moving ill and injured patients rapidly from the field to more robust health care facilities in the rear. In fact, last year, in support of Enduring Freedom, we air-evaced 1,352 patients, of which 128 were such critically injured patients. DOD's automated system, called TRAC2ES, allows us to track these patients person by person, from pickup to delivery, in real time.

And of course, we're part of a joint team. This joint service interoperability was demonstrated best during the crash of an Army helicopter last April in Afghanistan. The two pilots had massive facial and extremity fractures. The injured pilots were initially treated by an Air Force pararescueman delivered on the site by Army Special Forces helicopter. They were transported and then stabilized by an Army Forward Surgical Team. The two were then transferred to a waiting C-130, evacuated out of theater by a C-17 later, re-stabilized in flight by an Air Force Critical Care Transport Team. Ultimately, they arrived for surgery in a military hospital in Germany within 17 hours of the impact with the ground in Afghanistan. This is just one seemingly unbelievable, but in fact, increasingly routine example of our integrated medical operations.

We also owe our troops the security of creating robust mechanisms to record and retain data from the field to extend and enhance our force health protection efforts. Using automated systems, we've documented and centrally stored 11,600 electronic medical records from Southwest Asia since 9/11. The tools are now in place to collect relevant environmental exposure data and to forward them for centralized analysis. This linkage between individual patient encounters and environmental data is critical for any future epidemiologic studies. We're proud of our comprehensive Joint Force Protection Program and are confident in our ability to execute our mission together in any environment.

I'd like to pass it over now to Admiral Cowan.

Cowan: Thank you very much.

Going last means you have to have the most flexibility. We do everything jointly. And so everything that has been said is something that we all do in lockstep. There's hardly anything that we don't coordinate on. And so I won't go through and repeat many details of what Navy medicine does because you can take what my two colleagues said and kind of paint it dark blue, and that's what we do.

One thing you may not know about Navy medicine, you may notice that you don't see a Marine uniform here. Navy medicine provides the health care to the Marine Corps as well as the Navy. So you find my 3,000 deployed doctors, nurses and corpsmen on ships, hospital ships, fleet hospitals, and ashore everywhere a Marine goes. There was a wonderful quote from one of our Marine four-stars recently who said, "No Marine ever took a hill out of the sight of a Navy corpsman."

If there's a meta-message that I think carries the essence of what we try to do, it's that the Department of Defense medical department has taken the World Health Organization definition of "health" and turned it into policy and doctrine and action; and that is that health is a complete state of mental, physical and social well-being and not just the absence of infirmity or disease. I think everything that has been discussed here has talked about the imperative of first building people who have the resilience and the strength and flexibility to go do any of the myriad of missions that we ask our fighting forces to do, that we have taken our investment portfolio and moved it from being a reactive system, only reacting to sickness and disease, and moved it into major investments in both promoting and then maintaining the health of people and the families of the people that we send to war.

Secondly, that the umbrella of protection from environmental hazards, as well as the hazards of weapons of mass destruction, is a multifaceted network; rather than depending on one point, it's a system of systems rather than a particular thing that we do. And we have some good evidence that this works. Only a couple of years after Desert Shield/Desert Storm, I was the Joint Task Force surgeon for the 25,000 Americans and 25,000 coalition that went to Somalia. And we, using the principles that we learned out of Desert Storm -- in very primitive ways compared to what we do now -- had record low incidents of disease non-battle injury, we call DNBI. We used to accept that more people were taken out of the battlefield from disease and accidents than battle casualties, and we don't accept that anymore. We have followed through on all of our deployments, certainly, in the Balkans. We're seeing exactly the same thing; that you're safer and healthier in a deployment than in your home unit in many, many cases.

The technologies that have been described make as big a revolution as the technologies you are all more familiar with in weaponry. Small numbers of smart weapons were deployed very effectively in the Gulf War. Large numbers of them would be deployed if we go to war now. And the technologies that we are sending out are not the old Fox vehicles and the primitive detectors that oh, chirped off and went off at every whiff of everything that came by.

We have improved tracking and accountability, and that's a work in progress we're still working on. The big information systems that accumulate massive amount of data on hundreds of thousands of people are problematical - lag behind sometimes. But we've talked about the TMIP program and our other information technologies, and we're getting there very quickly.

Finally, I would just -- I would wrap up. This is still a work in progress. We advance these efforts every day. About an hour before I came over here, I received an e-mail from the medical officer assigned to the Marine Corps describing that we are beginning now to field an R&D product that the Department of Defense pushed through the FDA process -- has now have approval for a quick-clotting bandage of sorts that can be put on an external hemorrhage and accelerates the clotting of blood many times over, something that we feel is very important for saving lives in a battle environment and a very big advancement for us.

With that, I will stop and turn it back over to Dr. Winkenwerder for your questions.

Winkenwerder: And with that, let me call up -- thank you very much to all of you, and you guys just stay right here -- Jon -- call up Dr. Jon Perlin. Again, I want you to know that we work together very closely with the Veterans' Administration. Obviously, in today's time, today's situation, our need to think about the future and this transition and pass off between DOD and VA is very important.

So I'm going to turn it over to Jon for a couple of comments about what we're doing.

Perlin: Thank you. Good morning. And thank you, Dr. Winkenwerder.

With thousands of U.S. troops preparing for renewed conflict in the Persian Gulf, I'm grateful for the opportunity today to talk about veterans. Over the past 10 years, VA and the Department of Defense developed robust processes to address potential health consequences of deployment, to provide high-quality health care and disability assistance to active-duty personnel and to veterans. We're better prepared to do this today than at any other time in our history.

Three of VA's major missions are well-known: delivery of direct medical care, research and medical education. But there is a fourth critical mission. The VA health-care system is the backup to military hospitals in the event of war or other national emergencies.

You might not be aware that VA is the largest integrated health- care system in the United States. It's also recognized as a leader in quality health care. Therefore, service members can be assured that should a contingency backup mission be activated, VA stands ready to provide state-of-the-art care to ill and injured service members.

Let me outline what VA intends to offer service members who developed -- who have been deployed to a combat theater.

First, VA and DOD have developed a set of joint clinical practice guidelines, as mentioned by Ms. Embrey, for the examination of service members after a military deployment. This examination protocol is designed to address potential health consequences, such as those seen after Operation Desert Shield and Desert Storm.

And two, VA has established two war-related illness centers, one here in Washington, the other in East Orange, New Jersey. These centers provide clinical research and education programs related to deployment health issues.

Third, VA now has the authority to provide health care for two years to former military members who served in a combat theater, even without proof that their injuries or illnesses were caused or aggravated by their military service. The two-year time period begins when the military member is discharged or retired from active duty.

VA applauds the efforts of the Department of Defense to prevent health problems among deployed troops and to provide immediate care for combat casualties. Today's display of high-tech equipment and preventive medicine programs clearly demonstrate the commitment of DOD to our -- to the health of our troops.

We look forward to working collaboratively with DOD to address force health protection and veterans' health issues now and in the future. Both the Departments of Defense and Veterans' Affairs have learned many lessons since the Gulf War. Our troops can go into battle knowing that their government is committed to caring for them both on the battlefield and after they leave military service. We're proud to serve America's heroes every day.

Thank you.

Winkenwerder: Thank you, Dr. Perlin. And thanks to everybody for the information you shared.

Now I'd like to open it up for questions.

Q: Dr. Winkenwerder, I have two questions, and perhaps Dr. Winegar could answer one of them, if you would. Number one, have all of the troops, all of the American troops that have been deployed to the Gulf region, have they all had smallpox and anthrax vaccination? Or are there exceptions, for instance, someone who would be far afield at sea --

Winkenwerder: Those programs are both going very well. We track the numbers -- I personally track the numbers every week, and we are fast approaching a 100 percent rate of vaccination for all those that are deployed.

Q: And, Dr. Winegar, just something titillated me. I see the antidote treatment nerve agent autoinjector. Is that for one particular nerve agent? Does it cover a spectrum? And what does "autoinjector" mean? Is it something you -- (off mike) -- and it automatically injects?

Johnson-Winegar: It does cover the entire spectrum of nerve agents, and it's actually -- there's actually two versions there. One is a dual set of injectors, and then the second is our new, improved version where they're combined into one set. And by "auto," that's exactly right. When a service member is given the order to inject, all you have to do is sort of stab it into your thigh and it automatically injects the proper amount of material.

Q: And this is before -- before you are even affected to provide protection, or is this after your nerves are affected?

Johnson-Winegar: It can be used both ways. You should take it as soon as you have any kind of indication that you might have been exposed, but before symptoms are apparent. And it works on the acetylcholinesterase receptor system. It can also be given post- exposure when larger doses are given by a combat medic.

Q: So -- I'm sorry. There would not be side effects for using it -- say there were indications you might have been exposed and you took the thing. There wouldn't be major -- perhaps major side effects?

Johnson-Winegar: That's correct.

Q: Dr. Winegar, I have two questions. Could you explain how quickly the biological detectors can actually detect and, you know, sound the alarm that a biological agent has been used? And number two, what's the status of the antitoxins for botulinum exposure for deployed troops?

Winkenwerder: I'll ask her to take the first question --

Johnson-Winegar: You go ahead.

Winkenwerder: No, you take the first question, I'll take the second.

Johnson-Winegar: Okay. Our bio detection systems have a capability of identifying the agents within about a 15-minute time period. That's a presumptive identification based on what's done in the field. After having collected an air sample or whatever, we always like to have a confirmatory test done in a standardized laboratory, and that, of course, would involve whatever time is required to transport the sample back to a lab that can do the, quote, "gold standard" type of analysis.

Winkenwerder: With respect to the second question, I think was regarding botulism or botulinum, we believe that we can protect against all threats, including that one. There will be protection, medical protection, for service members for that agent. And I'll leave it at that.


Q: Just to clarify what Dr. Winegar said, 15 minutes. So -- so someone in the vicinity of the detector would have breathed in whatever these agents were for 15 minutes before you knew that this was something you shouldn't be breathing. Is that --?

Johnson-Winegar: Well, the theory is -- these are what are known as point detectors. And you're absolutely right. The way they work is they're constantly collecting air from the environment, and then either depositing the material onto a filter which can be furthered analyzed, or depositing it into a liquid. And so you're right. If you're standing at the point where the detection system is, by the time it goes off, you have also been exposed.

The way we work around that is that these systems are placed out on the perimeter. They're far away from where the troops are actually gathered. And clearly, that leads to the obvious question that a very high priority for us in our bio program is to have what we call stand- off detection, to be able to identify at a distance. We have that capability now for chemical agents, where we can detect them at a distance of five kilometers away, based on spectroscopy. We don't have that capability yet on bio. We're concentrating on the point system, and that's a very high priority for us in our research programs.

Winkenwerder: Yes.

Q: From a practical standpoint, how many of these detection units do you have, and would you be able to, for instance -- you said for instance to have a stand-off detection -- as forces are moving into a certain area, how would you be able to protect them or to know one way or the other if that area is contaminated?

Winkenwerder: Let me just give you a quick answer to the first question. We have a sufficient number. And that's not an issue. But we're not going to, for operational security, go into detail of how many or where.

And I don't know -- the second part of your question -- ?

Q: The second part of is was, if you have forces moving into a certain area, how do you detect in that general area before the troops actually get there whether or not that area is contaminated or not?

Winkenwerder: I think -- I think she just answered that --

Q: Well, you mentioned the stand-off detection. But as you're actually moving into that area, I'm sure that -- you know, they were talking, for instance, about chickens on the top of trucks that -- now you've moved away from that sort of thing. What do you have in place besides those chickens?

Winkenwerder: We're not going to describe this in detail. It just wouldn't be appropriate for security reasons.


Q: There's a couple things Admiral Cowan said actually that I thought were real interesting, specifically about the diseases and non-battle injuries, and you said you're looking for much lower rates now. Do you have evidence? I guess Afghanistan's the best current or recent mission to compare this to. Are you seeing lower levels of diseases and non-battle injury, especially as they're taking troops out of action in Afghanistan, than you've seen, perhaps, compared to like Desert Storm or Desert Shield?

Cowan: I don't know of numbers from Afghanistan. The numbers that came back from the Balkans and Somalia were very well vetted and established, and it was -- they were very remarkable. We did at the end of Somalia have a breakout of malaria of returning forces, many of whom had just broken through their disease.

But yeah, we have very good numbers on those. I don't have them with me, but we can give you those kind of numbers if you're interested.

Q: And you spoke of FDA approval for the quick clotting bandage. Did you say that had been approved by the FDA?

Cowan: Yes.

Q: Does that mean that's going to be fielded any time soon?

Cowan: The message came to me this morning, one hour before coming here, that the Marine Corps is beginning to field the bandage.

Q: And can you just give us an overview of why this quick clotting bandage would be an asset on the battlefield?

Cowan: It's difficult sometimes to control hemorrhage following a penetrating injury, and this is one more tool that you can put well forward in the hands of a corpsman or a medic or even a infantryman that can help staunch the flow of blood and stabilize a person and keep him stable until you get him back where surgical intervention can do a repair.

Staff: Next? Yes, sir?

Q: For the surgeon generals, there's something pretty topical that was just released at noon by the Centers for Disease Control in their weekly morbidity and mortality report. They're reporting now that in a sample of civilians that have had close contact with military vaccinated, that five of the six civilians -- close contact -- have had serious complications or adverse reactions. Do you have any reaction to this adverse report?

Winkenwerder: Let me take that question. And I'll just summarize by saying --

Q: I have a second question on a different subject.

Winkenwerder: Okay. But I'll summarize by saying our experience with the smallpox vaccination program, working with all three services, and following all adverse events very carefully, very scrupulously, through the military Vaccine Program Office, which is under General Peake and communicates with me on a daily basis, practically -- our experience is very good.

We will be releasing a comprehensive report on all of our experience to date in the very near future. And I would prefer to have it come out in that time, because it will be submitted to a medical -- a major medical journal, and if I talk about that now, then it creates problems for their reviewing and accepting that publication.

Q: I'm asking for a point-specific response to something that was released at noon on an embargo basis.

Winkenwerder: And what is the specific --

Q: The CDC report on the adverse reactions of civilians.

Winkenwerder: And what's the question?

Q: The question: Do you have any -- were you aware of the report? It looked at --

Winkenwerder: Well, if it was just released at noon, no.

Q: Well, you might have had a heads-up, though. That's all I'm asking.


Winkenwerder: We haven't reviewed it yet.

Q: A PB -- I'm not going to try to pronounce it. (Laughter.) Has the president been requested by CENTCOM to sign off on the waiver that would allow PB to be used for troops?

Winkenwerder: Let me clarify that. That drug is called pyridostigmine bromide. It is an antidote -- PB for short -- it is an antidote [pretreatment] for certain kinds of chemical or nerve agents. And it is now FDA approved. So, no presidential waiver is needed for use of that drug for those --

Q: (Inaudible) -- before FDA approved it, but that's become moot now, is that it?

Winkenwerder: It is moot because the FDA has reviewed it and approved it, and we appreciate their action to do that.

Q: Is PB being issued right now?

Winkenwerder: I'll turn to the surgeons in terms of -- it is available in the field, and stocked, I believe.

Peake: It's forward deployed, my understanding is, at the combatant commanders level. They haven't decided whether they want to issue it at the soldier level for individual use. It would only be used on the order of the commander given the threat.

Q: Is a soman threat seen as pressing or not such a --

Peake: I really can't discuss, you know, that kind of --

Winkenwerder: We're not going to talk about individual threats.

Q: I thought we were told recently that it wasn't indicated -- its use was not indicated at the present time. I think Army told us that.

Winkenwerder: What's your question?

Q: I think we were told in the last couple of weeks that its use was not indicated. I think the Army addressed it -- Army chem/bio things.

Winkenwerder: That the use for PB was not indicated?

Q: Right. Something to that effect.

Winkenwerder: I'm not going to validate that here. What I would say is just what I've said in terms of it's FDA-approved, it's in the field, it would be used if it is deemed useful or necessary by the commanders and the medical people supporting them.


Q: I'm sorry, when was that FDA approval given, do you know?

(Off Mike Staff): About a month ago.

Winkenwerder: Early February.


Q: Dr. Winegar, the joint chiefs testified just last month that their confident, their forces can operate in a contaminated environment and weather a chem/bio attack for an extended period. But I wonder if you can expand on that. What's an extended period? Is it hours? Is it days? And how does that change over that -- over the time period? How does the risk change over the hours?

Johnson-Winegar: I think you might be referring to the wearability of our JSLIST suit, which is shown up here. And we currently have data to indicate that individual service members can wear that suit for up to 45 days when they're operating in an environment that might be contaminated. Once they know they have encountered any type of contamination, our doctrine and policy is for them to change out of that contaminated suit within 24 hours and put on a clean suit. And that's why it's important for us to have more than one available per individual.

Q: If they can wear that suit for 45 days, why do they need to change it in 24 hours?

Johnson-Winegar: They need to change it if the suit becomes contaminated.

Winkenwerder: Yes?

Q: Could -- I don't know if this is exactly in your purview, but there was some discussion a few weeks ago about what to do if soldiers who are exposed to biological weapons die, what to do with their remains. I think there was talk of initially cremating, and then maybe not. Could you tell us where that stands and what they can -- what the considerations are?

Winkenwerder: Yes. We carefully reviewed that issue. And it has been a joint review involving the Services, the Joint Staff, Mortuary Affairs, my office. And I'm pleased to say that our approach to this is very carefully grounded in science. We've spoken and worked with the Centers for Disease Control, with other agencies that are involved in international quarantine or any of those kinds of legal matters that might be of concern. It is our policy that all such service members, should that come to pass for them, would be transported back to the United States. There are no plans for cremation or incineration or deep pit burial or anything of that sort. And --

Q: Can I ask you something?

Winkenwerder: I would -- it'd probably be best to defer providing a complete announcement on that right now because we are still working with authorities in the U.S. with respect to a couple of remaining issues that principally relate to once a body was returned to the United States, how that would be handled when one has to go back to the local community or through a state. And so there's some issues that are being worked out.

Q: What, can you tell us what agencies that you -- are concerned about that? Is that a Homeland Defense thing, or is it CDC, or -- ?

Winkenwerder: Probably at least those two, maybe others. But it's a coordination process. We want to make sure we get it right. But there's been a very careful review. And essentially this is the policy that we have followed. But we believe, backed by science, that there are fully safe ways to return any contaminated remains to the United States.

QWas there a time when you were thinking that you were going to be cremating and then it was changed, or was that reporting erroneous?

Winkenwerder: There may have been some who thought that. I won't speak for them. But it was certainly erroneous from the standpoint of being the policy.


Q: Is the Pentagon continuing to investigate the illnesses that came out of the war 12 years ago? And if so, are there any new conclusions along those lines? And what's the comfort level this time in being able to avoid that level of illnesses and that sort of mystery nature to them?

Winkenwerder: We are continuing to work on those issues. There is a very robust research program that is ongoing that involves the Department of Defense and the Department of Veterans' Affairs, some large-scale epidemiologic studies, some other studies that focus on smaller groups, that attempt to better define any cause-and-effect relationship between an exposure and a subsequent disease or illness in some cases that may be occurring not just months but years or many years after such an exposure. I would just say that that work is ongoing. We fully support that work. We believe it's important.

But one message I would leave you with is that we, because those events occurred or because there were soldiers and servicemen who came back with certain symptoms in some cases, we want to take the lessons from those experiences, and that's what we've described to you today, to have a better baseline of information when people are deployed that tells us about their health, better surveillance in the theater, and collection of information in a more disciplined way to look at people after they return.

What made the research -- or has made the research difficult is, if you don't have that baseline of information or your collection of information in the field is spotty and your collection afterwards is not uniform, it's very difficult to do the research. So that's in many cases why it's taken so long, is that it's very tedious research.

Q: By the better baseline, you mean the 30 million serum samples you now have?

Winkenwerder: I mean the serum samples, the ongoing physical examinations --

Q: (Off mike) -- sample collection?

Winkenwerder: Pardon me?

Q: How new is that, the sample collection?

Winkenwerder: General Peake?

Peake: We've been doing it since the '80s, but we've refined the discipline to that process. It's part of the HIV collection, and then within 12 months of a deployment, you get a serum sample if you're going overseas.

Q: So that was done before '91 for the soldiers going abroad.

Peake: Yeah, but in terms of archiving it the way we're doing now and having a discipline to the system where within 12 months of a deployment, that you get a new sample, that is what changed.

Winkenwerder: Let me take one more question and we're going to have to wrap it up for our time.


Q: I have a question about the battlefield cremation issue. I know you said it's grounded in science, your decision; but did opposition from military families and that come into play at all in your decision process?

Winkenwerder: No.

Q: It didn't.

Winkenwerder: No, we certainly listened and want to be sensitive to both service members and their families on an issue like this. Obviously, we want to do the right thing. And the right thing in this kind of situation ought to be something that's carefully grounded in good science, and we believe we've done that.

Q: Thank you.

Winkenwerder: Thank you very much. We appreciate your coming here. And I invite you to take a look at some of the display items, particularly the surveillance system.


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