III. BACKGROUND

A. Importance of Preventive Medicine

During military deployments, the importance of preventive medicine (PM), or preserving combat readiness and preventing illness and injury, cannot be overemphasized. Servicemembers often face increased exposures to hazards, endure disruption of basic hygiene and sanitation, and may have a reduced resistance to disease. Management and control of disease-carrying pests is very important in limiting the spread of infectious diseases to vulnerable troops.

Each service assigns personnel to implement PM responsibilities. Preventive medicine assets protected the health of servicemembers during the Gulf War, including providing pest control. Insects (mosquitoes, flies, and fleas), ticks and rodents often carry diseases. Controlling disease-bearing pests interrupts the transmission of these diseases. Typically, PM personnel first determine the pest threat in an area of operation and then implement physical control measures, such as careful selection of locations for units and facilities, and application of repellents and pesticides.[1] Since many diseases thrive in the harsh, unsanitary conditions found in war, failure to practice satisfactory field sanitation allows unnecessary disease to occur. Preventive medicine measures need vigorous command emphasis to succeed, and must be implemented at the beginning of any deployment to minimize casualties due to disease and nonbattle injury (DNBI).[2] Important steps in minimizing pest problems include implementing proper sanitary controls and using pesticides appropriately.

B. Expected Threat from Pest-Borne Diseases

Historically, campaigns fought in the Middle East have been accompanied by diseases that played a disproportionate role in determining the outcomes. As recently as World War II, disease and health problems ravaged fighting forces deployed to the region on a par with hostile action.[3] Because sand fly fever was widespread in Iran and Iraq during World War II, US military health officials viewed it as potentially one of the most serious infectious disease threats of the Gulf War. Approximately 697,000 US servicemembers served in the Kuwait theater of operations (KTO) during the Gulf War. During this massive deployment, the military medical community was concerned that pest-borne diseases would threaten servicemembers’ health.

C. Preventive Medicine and Pest Management Organizations and Programs in the Gulf War

During the Gulf War, the Department of Defense (DoD) assigned pest management responsibilities to several organizations. The Office of the Assistant Secretary of Defense for Health Affairs, supported by the expertise of military preventive medicine officers and military contingency operations planners, developed and disseminated general DoD preventive medicine policy. The respective services’ surgeons general developed their own service-specific preventive medicine policy. Each service also has support organizations that aid in providing effective PM support.

DoD assigned pest management policy to the Under Secretary of Defense for Acquisition and Technology, with the Deputy Under Secretary of Defense for Environmental Security having day-to-day responsibility. Two organizations provided department-wide preventive medicine support: the Armed Forces Pest Management Board (AFPMB) and the Armed Forces Medical Intelligence Center (AFMIC). The AFPMB 1) developed and recommended pest management policy; 2) served as the scientific body on pest management issues for all DoD components; 3) organized pest management research and development functions; 4) coordinated DoD pest management activities; and 5) approved the introduction, stocking, and removal of pest management materials approved for the military supply system.[4] Through its Defense Pest Management Information Analysis Center, the AFPMB provided Disease Vector Ecology Profiles, publications that helped prepare deploying units for disease risks they might have encountered during deployment. AFMIC provided and maintained current disease risk assessments and information on parasitic and communicable diseases, as well as other aspects of medical intelligence. An AFMIC representative served on the AFPMB and acted as liaison between the two organizations.

During the Gulf War, the US Army Center for Health Promotion and Preventive Medicine (USACHPPM), formerly the US Army Environmental Hygiene Agency, remained the principal source of toxicological information, pesticide monitoring, and pesticide resistance testing.[5]

Each branch of the military deployed its preventive medicine assets to protect US personnel in the Gulf. The Army and Navy normally train and certify enlisted preventive medicine personnel to apply pesticides during deployments and field training exercises. Personnel who apply pesticides are known as pesticide applicators or simply applicators. Navy applicators support the Marine Corps. Air Force pest control is a civil engineering specialty. Unlike Army and Navy preventive medicine personnel, Air Force pest controllers applied pesticides while stationed at permanent Air Force installations, as well as when deployed.

Navy and Marine Corps units were supported by two types of preventive medicine organizations: the Navy Disease Vector Ecology and Control Centers (NDVECCs) and Navy Environmental and Preventive Medicine Units (NEPMUs). NDVECCs provided technical and specialized vector prevention and management services and supported operating forces and shore installations to prevent disease vectors and pests. NEPMUs provided expert, specialized technical services, consultation, advice, and recommendations on preventive medicine and environmental health matters.[6]

At the time of the Gulf War, the US Air Force School of Aerospace Medicine provided pest management consultations, operational entomological research, medical readiness training, and environmental health personnel training in pest and pest-borne disease surveillance. The US Air Force Armstrong Laboratory, Occupational and Environmental Health Directorate, provided pest management consultations and operational entomological research. The Armstrong Laboratory is now part of the Air Force Research Laboratory. The Air Force Civil Engineering Support Agency, formerly the Air Force Engineering and Services Center, implemented pest management policy and programs. These included worldwide professional pest management technical assistance, pest management support during combat and disaster relief operations, base level training monitoring, pest management and pesticide database maintenance, a liaison with the medical element on all environmental and health-related issues, and coordination with other military services and appropriate governmental agencies on pesticide disposal and the DoD environmental pesticide monitoring program.[7]

Following are summaries of the preventive medicine and pest management activities for each service and the organization of each service’s pest management operations during the Gulf War deployment.

1. Army

The Army approached preventive medicine and pest management from various organizational levels—division to corps, and finally, to echelons above corps. At each level, one or more organizations provided preventive medicine and pest management support.

Preventive medicine units provided a variety of services, including pest management, to other units assigned to them. Preventive medicine units periodically conducted field sanitation inspections and applied pesticides or oversaw the application of pesticides, as necessary. In addition, they provided training as needed. Individual units had two-man field sanitation teams (FSTs) that provided basic field sanitation activities, including limited pesticide application capabilities.

Army preventive medicine units and personnel were assigned to all levels, from the Theater Army Headquarters (ARCENT), to the two Army Corps, down to the division level. At the ARCENT and Corps levels were various medical detachments that performed preventive medicine functions. The 714th Medical Detachment was the only entomology unit in the theater and it was under ARCENT, as were the 105th Medical Detachment (Environmental Engineering) and the 983rd Medical Detachment (Environmental Sanitation). These three detachments provided general support for all Army forces in the theater. Under the medical brigades of VII Corps and XVIII Airborne Corps, environmental sanitation detachments and epidemiology detachments provided direct support to their Corps. Each division included a preventive medicine section to provide direct support for its division.

2. Navy and Marine Corps

Navy preventive medicine personnel provided support, including pesticide applicators, for Marine Corps units. In August 1990, in-theater Navy and Marine Corps preventive medicine assets included two entomologists and 48 preventive medicine technicians. The senior entomologist served as the preventive medicine chief at the surgical and support company facility in Al Jubayl.[8] The I MEF preventive medicine contingent also included five environmental health officers.[9] By the end of 1990, more Navy preventive medicine resources arrived in theater to support the 2d Marine Division’s reinforcement of I MEF.

Most Marine battalions and air squadrons had an assigned Navy Preventive Medicine Technician (PMT).[10] On-site PMTs provided routine services for the forward units, with equipment and pesticides coming from the Field Service Support Group, Division, or Air Wing assets. PMTs were tasked to conduct vigorous training in preventive medicine, including field sanitation, personal hygiene, and pest control. Unit PMTs applied pesticides to control biting flies and other insects. Two-member teams under an entomologist’s direct supervision provided emergency or large-scale pest control services.[11]

3. Air Force

Air Force pest control personnel were located at fixed facilities in Saudi Arabia and other countries in the KTO. The Air Force had no entomologists in theater and actually depended on the Army and Navy entomologists for support.[12] There were 37 in-theater Air Force pest control personnel, including pesticide applicators, assigned to civil engineering units handling pest management.

D. Logistics

The US military supply system included a variety of pesticides and repellents used throughout the KTO. Investigators have not been able to determine the amounts of each pesticide used during the Gulf War. They were only able to find material ordering data, not actual usage data (i.e., application rates). Additionally, US forces purchased locally available pesticides due to depleted inventory supplies or delays in distribution.

Preventive medicine and pest control personnel said fly control products were most frequently purchased locally, followed by rodent control products. Some pesticides, including fly baits, may have been similar to those in the US supply system. However, not all locally-purchased pesticides were registered with the Environmental Protection Agency (EPA) and some had labels requiring translation into English.

Pest controllers and preventive medicine specialists and technicians dealt in various ways with the problem of labels they could not read. In some cases the label identified ingredients in English so applicators used that information to determine what to do.[13] Several applicators obtained demonstrations or translations by local personnel.[14] Others relied on senior personnel for guidance.[15] One applicator stated she handled an unknown pesticide without guidance.[16]

E. Concerns About Pesticide Use in the Gulf War

Pesticides emerged early on as one of many risk factors potentially contributing to Gulf War veterans’ unexplained illnesses. Veterans, veterans’ groups, researchers, and government agencies expressed concern about the possible association between pesticide exposure and illness. Researchers knew that organophosphate (OP) pesticides and carbamate pesticides at high doses were toxic to the nervous system, and sometimes produced long-term neurological problems. Additionally, researchers were concerned about the potential for toxic interactions among multiple OP pesticides, carbamate pesticides, organophosphorus chemical warfare agents known as nerve agents, and pyridostigmine bromide (PB). PB was provided to servicemembers as a prophylactic measure against attack with the nerve agent soman.

OP pesticides are chemically similar to the nerve agents. OP pesticides, carbamate pesticides, and nerve agents exhibit the same toxic mechanism; that is, inhibition of a group of important enzymes known as cholinesterases. One type of cholinesterase, known as acetylcholinesterase, is critical to the proper functioning of the nervous system. PB is a carbamate, and it is therefore chemically similar to carbamate pesticides. Like the carbamate pesticides, PB also inhibits cholinesterases. Thus, OPs, nerve agents, and carbamates including PB are placed in an encompassing group known as anticholinesterases. The reader should note that nerve agents are far more toxic than the OP pesticides, carbamate pesticides, and PB.

During the past several years, Congressional committees have held numerous hearings and issued several reports on the subject of the health of Gulf War veterans. Several of these made references to various environmental exposures during the war, including pesticides.[17] A Senate Veterans’ Affairs Committee report commented inconclusively on pesticides’ role in Gulf War illnesses: "Most troops were likely exposed to some level of a variety of these chemicals although the amount or level of exposure is not known."[18] Partly because of the uncertainties about exposure, DoD decided to investigate the use and management of pesticides during the Gulf War and evaluate the extent of pesticide exposures to servicemembers and potential health effects.

F. Institute of Medicine Literature Review

On February 18, 2003, the National Academy of Sciences Institute of Medicine (IOM) released its report, "Gulf War and Health, Volume 2, Insecticides and Solvents." Funded by the Department of Veterans Affairs, this 629-page report on peer-reviewed medical and scientific literature review focused on long-term adverse health outcomes associated with exposure to insecticides and solvents. Its purpose was not to judge whether veterans wee exposed to these substances, but to assess the scientific evidence regarding long-term health effects associated with exposure to specific insecticides or solvents that were possibly present during the Gulf War.

To draw conclusions, the IOM relied on epidemiological, occupational studies of workers, including servicemembers, exposed chronically to insecticides.

The IOM grouped its conclusions according to the following categories:

The IOM concluded that there was "limited/suggestive evidence of and association" among the following:

The evidence is limited by the inability to rule out chance and bias, including confounding factors, with confidence. The IOM did not list any insecticide associations with "sufficient evidence of a casual relationship" or "sufficient evidence of and association."[19]

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