DNBI key risk areas

Western standards of public health are virtually absent across much of Afghanistan and there is significant threat to the health posed by the environment, operational duties and physical effort summarised as:2   

Routine population-based epidemiological reporting through the weekly EpiNATO surveillance system consistently highlights gastrointestinal illness, dermatological conditions, musculo-skeletal disorders and diseases of the teeth and oral cavity as the main presentations to Role 1 medical treatment facilities.

Sustaining the force

Reception, staging and onward integration

Reception, staging and onward integration (RSOI) is an in-theatre induction programme designed to prepare personnel for their generic operational role in the TFH AO. To further develop and support the first line of the Med FP network, the EH team redesigned and developed the RSOI EH briefing to include refresher training for CHD personnel (Figure 1) and health threat briefings for CHA personnel identified from nominal rolls provided by DMSTG and School of Health (Germany). Specialist support and sustainment required to effectively discharge their duties within the TFH AO was provided (Figure 2).

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Figure 1

Delivery of combat health duties refresher training during Reception, Staging and Onward Integration.

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Figure 2

The combat health duties support pathway.

Medical personnel were briefed separately on the health risks posed by specific locations and their role within the Med FP network and commanders were actively encouraged to visit the EH team to receive historical and current tactical Med FP briefs.

The generic RSOI EH briefing was changed so that it reflected the main health threats in the TFH AO; this new TFH-specific briefing remains responsive to changes in health threats, lay down, available resources and infrastructure development. RSOI EH briefings continued to be the primary means of securing theatre location-specific health education at the point of entry. Instructional specifications were also tailored to meet wider requirements such as the introduction of ballistic pelvic protection and the LifeSaver water bottle.

Steady state Med FP delivery

Head Quarters Joint Force Support (A) was originally based at Kandahar Air Base with the EH team managed by the Camp Bastion-based medical intelligence officer, until its relocation to Camp Bastion in December 2009. This meant that for the first time the SO2 Med FP would be fixed in the same location as the EH Team, the rear support elements of TFH, the UK Med Group and much closer geographically to the TFH HQ at Lashkar Gah. The move allowed the SO2 Med FP to take effective tactical command of the EH team, making the task of the EH team focused on health risk and the maintenance of combat efficiencies.

Increasing and improving EH capability

At the start of Op HERRICK 12, the EH team was established for four personnel, later increased to six as a result of the Op HERRICK 12 Theatre Capability Review. The team was a 50 : 50 split of Royal Army Medical Corps and RAF EH Techs. In addition to their specialist reactive work, they were mandated to conduct at least one Med FPA per tour of each tactical base location in TFH.4 Previous operational lay downs may well have allowed this but a rise in tactical base locations from 36 on Op HERRICK 9 to over 180 on Op HERRICK 12 (reducing to less than 140 on Op HERRICK 14) left this target impossible to achieve. Furthermore, as a consequence of the tactical lay down and limited EH manpower, a greater reliance had to be placed upon forward medical support elements to engage in first line Med FP provision to ensure steady state delivery (Figure 3).

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Figure 3

Steady state Med FP delivery. EH, environmental health; LO, liaison officer; MED FP, medical force protection.

The rapid proliferation of tactical bases, the greater occupational health risk posed by the CPs and the limited size of the EH team resulted in the deployment of EH assets being risk-based in the first instance. The EH team were tasked to target those health issues most likely to expose personnel to the greatest risk and therefore jeopardise the mission. The targeting of limited, specialised resources to achieve the greatest effect proved much more efficient than the inherited fixation on visiting a prescribed number of tactical locations within a given time period.

Pragmatic health messaging

Health promotion and education remains a central tenet of successful Med FP delivery across a diverse and high tempo operational environment. The need for FEs to take ownership of Med FP is grounded in the correct training and passage of information. The engagement and support of both TFH and the medical CoC were crucial in ensuring that preventative actions were in place and any omissions remediated in a timely manner. Health education was seen as key to securing continual improvements in health defence, reducing disease non-battle injury (DNBI) and influencing infrastructure development. A wider drive to improve Healthcare Governance also saw Med FP incorporated into the assurance framework to enable a more consolidated approach to risk management.

Various media and resources were used, including BFBS Radio, poster campaigns, routine orders and health fairs to deliver effect and engender positive change. Active health promotion remains reactive in response to an ever-changing lay down. Message framing of health threats were related to real issues and examples encountered on the ground to achieve maximum impact.

Disease recording and reporting

The ability to measure activity and gather data on DNBI profiles is vital to inform the decision making processes at the operational and strategic levels, while assisting the shaping of future capabilities. This in turn shapes the requirements at the tactical level securing the well-being of personnel with the provision of measured interventions and support.

Communications and Information Technology support across the battlespace continue to be a limiting factor in the gathering of reliable medical information, with many CPs having only a radio as their primary communication platform. This hinders rapid data collection and can introduce error into the collection of epidemiological data through miscommunication and overconsolidation. The revised EpiNATO data collection system aims to give greater granularity of DNBI incidence across the CFs but will only be as successful as the training provided and the communication equipment used for its collection, which remains an ongoing requirement. That said, recent statistics now give a better indication of true DNBI incidence, with reporting error minimised through collective training both on the ground and during Medical MST. Disease notifications, such as FMed 85s (Disease Notification forms), gastrointestinal illness reports and climatic injury returns, have also improved in terms of both timeliness and completeness.

Prior to the deployment of 4 Mechanized Brigade, there had been an aspiration that all CHD personnel would submit a weekly situational report to the EH team highlighting key issues, and the control measures being undertaken, at their location. Whereas this may have been possible when TFH had less than 40 tactical base locations, it was never a realistic consideration for Op HERRICK 12 and beyond. As an alternative, CHD personnel used various methods of communication to relay information to the EH team, normally via their local medical treatment facilities or the medical liaison officer at each CF HQ. The communication flow was not one way and the EH team would routinely track down CHD and CHA personnel for an accurate ground brief as well forwarding key Med FP updates to the CF HQ for dissemination. This flow of information included control strategies based upon the analysis of the weekly population health surveillance statistics and those obtained during sentinel event reporting. HQ TFH were also quick to deploy their CHD trained personnel into all new tactical base locations to establish first line Med FP controls where they were needed most.

Simple changes to reporting can reap significant rewards. During Op HERRICK 13 it was decided to change the format and layout of reports generated by EH assets following deployments to forward locations. Simple changes, including ‘rebadging’ from EH advisory visit to Med FPA ensured that recognised military terminology was used and increased the emphasis on the importance of the report as well as bolstering the priorities of EH personnel to gain access to required transport assets. The inclusion of photographs for each issue raised in concert with priority/time-based solutions and suggested points of contact were well received by TFH and FEs alike. So as to ‘close the loop’ a feedback mechanism was also introduced which formed the basis of Unit-level action plans, allowing progress to be monitored and assistance given where necessary.

Sustaining UK standards of EH support in a kinetic operational environment

Although the EH team enjoyed a greater degree of task flexibility, the level of insurgent activity and deliberate operations often hampered access into or out of the THF AO and its various CFs. A common misconception is that movement around the Op HERRICK AO is largely provided by support helicopter, whereas the reality is that the majority of the locations that require the immediate assistance of the EH team were normally only accessible via foot patrol or vehicle move.

Insurgent activity, limited airframe availability and lack of force protection on occasions prohibited the priority movement of the EH team to investigate communicable disease outbreaks, which were predominately gastrointestinal in nature. On such occasions, the EH team would directly engage with the Regimental (or Unit) Aid Post to seek details of the cases and talk the medical staff through the completion of the relevant questionnaires, reports and returns. Control strategies were based on a simplistic three tier system of immediate containment, source identification and prevention of further cases. All such theatre outbreaks were notified immediately to the Deputy Chief of Staff at HQ TFH and the local CF Commander in addition to the existing medical CoC, normally via the Med LO embedded at the operational CF HQ. It is more or less impossible to meet all the UK standard protocols for communicable disease investigation when the population at risk is actively involved in daily deliberate military operations. HQ Joint Force Support Standing Operating Instructions were created to bridge this procedural gap and have, with routine review, proven to be invaluable. The technical direction in these documents reflected the operational limitations and gave pragmatic solutions to achieving the three tier control strategy.

Expansion and maintenance of influence

With effect from June 2010, TFH resubordinated to the command of Regional Command South West based in Camp Leatherneck, on the Bastion plateau. The co-location was ideal for the creation of an effective working relationship with NATO preventative medicine partners and the handover of the tactical bases in the north of Helmand to units from the 2nd US Marine Expeditionary Force. During the handovers, the EH team deployed jointly with US Navy Preventative Medicine Teams and conducted on site handovers ensuring that the incoming unit understood the relevant health threats in each location. The working relationship developed further with the US Navy Preventative Medical Technicians adopting the UK EH situational report format for their own tactical reporting and the use of Head Quarters Joint Force Support (A) DNBI data to identify seasonal and geographical disease trends in their new AO.

Increased interaction with Regional Command South West medical elements to formulate contingency plans, establish working groups, develop policy and cross-pollinate best practice was subject to ongoing development. Disease outbreaks among the civilian populus saw multi-national engagement to manage the threat to International Security Assistance Force personnel as well as provide arms length support to the Government of Afghanistan.

Sustaining effect

The overall success of the Med FP network remains intrinsically linked to the exertion of EH influence upon the deploying elements during their PDT and MST (including RSOI). Once this foundation had been established, the Med FP first line was easier to support, mentor and maintain in theatre. In short, trained personnel knew exactly what was required of them and Command elements were more aware of overarching health management responsibilities. As with any mutually supportive network capability gaps were identified, such as the scale of application equipment required to sustain such a large number of CHD personnel. Subsequently this was addressed with the submission of urgent operational requirements for swing fog machines and compression sprayers.

The Med FP network also highlighted that a number of our more recently qualified combat medical technicians had very little formal Med FP training. This need has now been addressed and personnel from 1 Medical Regiment were the first to undergo the new 2-day combat medical technician Med FP course as part of their Op HERRICK 15 MST. This course is now mandated by PJHQ for all Role 1 medical personnel deploying on Op HERRICK.5 Personnel are also now validated, individually and as part of a team, during the Role 1 validation exercise. EH personnel from both of the operational divisions now sit as permanent members of the Role 1 validation health faculties for their respective medical regiments.

Enduring effect

The true effectiveness of the Op HERRICK Med FP network is not easily proven and is particularly evident in a professional environment that craves conclusive evidence of effect. The weekly UK DNBI was used as a measure of effect by HQ International Security Assistance Force International Joint Command and UK Joint Commands. Unfortunately, this method of data capture was limited as it calculates the percentage of DNBI on first recorded medical presentations and not the final diagnosis or impact upon operational effectiveness. Categories such as battle casualties and routine medical administration were also included in the final total. Scant regard was given to the number of working days lost or light duties awarded until revised reporting procedures during HERRICK 13 facilitated deeper interrogation of the data. The total number of working days lost to each category is the ideal method for identifying those diseases or events that truly reduce the combat effectiveness of a unit, although the granularity of the data captured remains unable to specify effect across specific cohorts, trades or specialisms where such manpower availability would be felt the most. Regardless of the need to qualify impact, the need remains to identify, assess and control health threats that impact on the ability to maintain full combat efficiency and operational flexibility in both the offensive and defensive roles.

As the operation draws down and transition continues to develop, the health risks to the Force will change. Mentoring activity will result in greater reliance upon ANSF to manage health risks and the infrastructure in which UK personnel will be living and working. As UK withdrawal progresses, new risks associated with food, sanitation, disease control and water supplies in association with closer working relationships with ANSF will require careful mitigation to balance the threat to UK troops with engendering self-reliance among the ANSF. Med FP interventions which consider cultural difference while ensuring that UK personnel are still protected will also be a challenge.