Summary
Public assessments by Department of Defense (DOD) officials have emphasized the seriousness of the military threat from chemical and biological (CB) weapons. However, neither DOD nor the services have systematically examined the adequacy of the current specialty mix of medical personnel for CB defense. Although some of the services have begun to review the adequacy of staffing of deployable medical units that would manage the consequences of chemical warfare scenarios, they have not done so for biological warfare scenarios. Joint protocols for treating CB casualties have recently been completed, but the services have not yet agreed on which health care providers should provide treatment. Relatively few military health care providers are trained to a standard of proficiency in providing care to CB casualties. The service surgeons general have begun integrating chemical and a few biological scenarios into their medical exercises, but no realistic field exercise of medical support for CB warfare had been concluded. DOD and the services have not fully addressed weaknesses and gaps in modeling, planning, training, tracking, or proficiency testing for the treatment of CB casualties. The resulting medical structure has not been rigorously tested for its capacity to deliver the required medical support. As a result, medical readiness for CB scenarios cannot be ensured.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change
from "In process" to "Implemented" or "Not implemented" based on our follow up work.
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Recommendations for Executive Action
Recommendation: To the extent that DOD views chemical warfare or biological warfare as a serious threat in its areas of operations and expects its medical forces to prepare for these contingencies, the Secretary of Defense should direct that the services and Joint Staff support completion of the Common User Database by concluding an agreement regarding which personnel are qualified to provide specific treatments. Without such an agreement, the services' medical models use different assumptions about which personnel are qualified to administer treatments, and the results are neither comparable nor readily defensible. This database should eventually be validated by proficiency testing of the identified personnel to help further refine training and specialty mix requirements.
Agency Affected: Department of Defense
Status: Implemented
Comments: The Joint Readiness Clinical Advisory Board (JRCAB) was charged with updating the Common User Database which describes treatment protocols and requirements associated with the provision of health support in the operational environment. The JRCAB developed a functional requirements proposal and proof of concept for the Common User Database. According to DOD, upon activation, the CUD would provide clearly stated requirements related to treatment protocols, which can then be used to develop specific provider training curricula to match the incidence of clinical events expected, and allow iterative cycles of validation. JRCAB developed planning objectives and milestones. After some delay, $2,000,000 was made available, and the contract for development of the Common User Database was awarded on 3/22/04. The DOD IG considered this recommendation completed as of 9/8/2004.
Recommendation: To the extent that DOD views chemical warfare or biological warfare as a serious threat in its areas of operations and expects its medical forces to prepare for these contingencies, the Secretary of Defense should direct that, in furtherance of a triservice approach to medical planning, the services and joint staff use these enhanced modeling capabilities to develop defensible and transparent risk assessments associated with various evacuation rates. The services and joint staff should develop and approve joint models and tools to support more timely, flexible, and integrated planning for these threats and enable effective updating of both long-term specialty mix evaluations and short-term combat medical requirements.
Agency Affected: Department of Defense
Status: Implemented
Comments: Overall, DOD and Services have developed and approved joint models and tools to support more timely, flexible, and integrated planning for these threats. The Services were requested to move forward in developing CB associated casualty rates that would enable the Medical Analysis Tool to provide requirements data for WMD environments. The U.S. has ratified NATO Medical Planning Guide for NBC Casualties, which establishes methodology for assessing NBC casualties and could serve as a basis for casualty rate determination. NATO data was reviewed for incorporation into DOD NBC casualty rates. The Services were to adopt approved NATO casualty rates and ready them for use in joint planning. Joint Staff designated the Joint Medical Planners Working Group as focal point for this purpose, and the planners working group agreed that NATO casualty data should be incorporated into Medical Analysis Tool (MAT). The Army has developed refined WMD planning factors based on the NATO data. The MAT has been updated with the WMD planning factors. The Joint Strategic Capabilities Plan (JSCP) was revised to eliminate the old planning factors and incorporate the Army-refined CB medical factors. JSCAP has been revised and coordinated with the Services, Combatant Commanders and appropriate agencies. As of 7/27/2005 DOD issued the Logistics Supplement to the Joint Strategic Capabilities Plan (JSCP) FY 2005 which provides major combat operations health service support planning guidance and the planning factors of concern. The Logistics Supplement to the Joint Strategic Capabilities Plan, which is used by CINC medical planners as guidance for the Medical Analysis Tool, contains guidance on evacuation.
Recommendation: To the extent that DOD views chemical warfare or biological warfare as a serious threat in its areas of operations and expects its medical forces to prepare for these contingencies, the Secretary of Defense should direct that the services develop CB medical training requirements and assess the effectiveness of the training with rigorous proficiency metrics and standards.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD has developed common training standards for different levels of personnel and proficiency metrics, and appears to be applying lessons learned from metrics to revise training standards. Efforts were underway to enhance NBC training. All short and long-term courses provided by Army Medical Department Center and School are to address medical management of NBC casualties. The Army is preparing exportable, tailored and scaleable courses on medical management of NBC casualties. The Navy directed that designated front-line health care providers receive 12-hour Army training program entitled, Biological and Chemical Warfare and Terrorism. All Military Treatment Facility commanders were directed to ensure designated front-line health care providers received a 12-hour training program, Biological and Chemical warfare and Terrorism. The Defense Medical Readiness Training Institute (DMRTI) analyzed service chemical, biological, radiological, nuclear, and explosives (CBRNE) training programs, conducted a commonality and gap analysis, and provided draft tri-service baseline curricula for medical specialties and reporting system requirements. DMRTI developed Tri-Service proficiency metrics and standards by March 15, 2003. DMRTI agreed on levels of training (initial, sustainment, advanced). General competencies and skill sets for each level of training were discussed and basic ground work established. As of 8/15/03 the CBRNE Emergency Medical Preparedness/Response Course is now the endorsed training program for initial and sustainment training. All medical personnel DoD-wide will be required to meet the learning objectives cited in the triservice CBRNE program. Courses utilized to meet an objective must have a suitable grading mechanism to award credit. Due to the large number of personnel that require training, the training goals will be implemented incrementally for the first three fiscal years. The Assistant Secretary of Defense for Health Affairs, ASD(HA) issued a policy memo on 1/9/04 to implement the Tri-Service CBRNE Training Program. The approved memo includes standards of proficiency necessary to support CBRNE readiness, describes who needs the training, frequency of training, a recommended Tri-Service training program, metrics to measure compliance, and reporting requirements. The standards of proficiency were developed to provide a standardized knowledge level for military medical personnel, civil service and civilian contractor personnel. Beginning in FY 2004, the standards of proficiency were required training for all military medical personnel throughout DoD. The Services were working on their Service specific implementation plans. Their first reports were scheduled for June 2004. As of 9/8/2004, the Services have implemented the 1/9/04 ASD(HA) policy memorandum and are generally in agreement on the standards. They are now submitting the CBRNE Standards of Proficiency Reports as required. The DMRTI is collecting the reports for presentation to the Force Health Protection Council for monitoring as required by the policy. The subject matter expert panels to reassess required training met in July 2006. The DMRTI expects to have requirements for core and enhanced training for all medical personnel coordinated and finalized by the end of September 2006.
Recommendation: To the extent that DOD views chemical warfare or biological warfare as a serious threat in its areas of operations and expects its medical forces to prepare for these contingencies, the Secretary of Defense should direct that DOD develop and maintain information management systems to monitor completion of required CB training and track the proficiency of medical personnel, at least for medical first responders and personnel in high-risk areas of operation.
Agency Affected: Department of Defense
Status: Not Implemented
Comments: Overall, DOD reported that it has pursued proficiency tracking of medical personnel as a high priority. Importantly, DOD significantly expanded the recommendation to cover all health providers, and also to include training for nuclear casualties. The Office of the Assistant Secretary of Defense for Health Affairs evaluated tracking systems options and requirements. Results continue to be reviewed for compatibility with training requirements developed pursuant to our recommendation that they develop training requirements and assess them with proficiency metrics. The central personnel tracking system is still under development. Meanwhile reports will be submitted to DMRTI on a quarterly basis to demonstrate the level of compliance until the standards can be integrated into the Defense Integrated Military Human Resources System (DIMHRS). Because training requirements are being reevaluated, the integration of CBRNE training standards into DMHRS has been delayed. As of 9/06 the CBRNE training standards are still not integrated into DIMHRS. The subject matter expert panels to reassess required training met in July 2006. DMRTI expects to have requirements for core and enhanced training for all medical personnel coordinated and finalized by the end of September 2006.
Recommendation: To the extent that DOD views chemical warfare or biological warfare as a serious threat in its areas of operations and expects its medical forces to prepare for these contingencies, the Secretary of Defense should direct that the joint staff, CINCs, and services increase the realistic exercise of medical support to a level commensurate with current CB threat assessments. To the extent that there is a threat of mass casualties, exercises should explore the limits of medical capabilities and the full consequences of scenarios that overwhelm them.
Agency Affected: Department of Defense
Status: Not Implemented
Comments: DOD has said that it recognizes the importance of exercising medical response as a core function of consequence management. DOD requested that the Joint Staff, in collaboration with CINCs, include CB medical participation in all appropriate exercises by March, 2003. They revitalized the Joint Exercise Working Group to include an updated charter. The Group will develop a joint medical exercise program and lay the framework for incorporating input from various specialty/CBRNE working groups. Joint Staff developed draft Defense Planning Guidance to increase realistic medical CBRNE in exercises for review by the Senior Policy Group in concert with the Joint Capabilities Integrated Development System. As a result, the 2004-2009 Defense Planning Guidance directed components to ensure sufficient specialized personnel and CB weapons training and force exercises throughout the program period, with training conducted to validated standards. Current requirements for the Global War on Terror have delayed overall project completion.
Recommendation: The Secretary of Defense should address the gap between the stated CB threat and the current level of medical readiness by clarifying DOD's expectations regarding medical preparation for CB contingencies and, as appropriate, direct the Joint Staff to integrate biological medical readiness in Defense Planning Guidance.
Agency Affected: Department of Defense
Status: Implemented
Comments: DOD has addressed the gap between the stated CB threat and the current level of medical readiness. It clarified expectations for medical readiness requirements with the services and theater commanders. It directed the Joint Staff to integrate biological medical readiness in Defense Planning Guidance. The 2004-2009 Defense Planning Guidance directed components to ensure sufficient specialized personnel and CB weapons training and force exercises throughout the program period, with training conducted to validated standards. Beyond improving the Defense Planning Guidance, it has also addressed the gap by completing action on several of our specific recommendations and continuing to make steady progress on others within constraints posed by the Global War on Terrorism.
