Chemical and Biological Defense: DOD Needs to Clarify		 
Expectations in Medical Readiness (19-OCT-01, GAO-02-38).	 
								 
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. While some of 
the services have begun to review the staffing of deployable	 
medical units for the capacity to manage the consequences of	 
certain chemical warfare scenarios, they have not done so for	 
biological warfare scenarios. Although joint protocols for	 
treating CB casualties have recently been completed, agreement	 
has not been reached among the services on which health care	 
providers are appropriate to provide treatment. Relatively few	 
military health care providers are trained to a standard of	 
proficiency in providing care to CB casualties. Although the	 
service surgeons general have begun integrating chemical and a	 
few biological scenarios into their medical exercises, 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	 
consequence, medical readiness for CB scenarios cannot be	 
ensured.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-38						        
    ACCNO:   A02330						        
  TITLE:     Chemical and Biological Defense: DOD Needs to Clarify    
Expectations in Medical Readiness				 
     DATE:   10/19/2001 
  SUBJECT:   Biological warfare 				 
	     Chemical warfare					 
	     Defense capabilities				 
	     Defense contingency planning			 
	     Emergency medical services 			 
	     Emergency preparedness				 
	     Terrorism						 
	     Army Defense Readiness Program			 
	     Army Professional Officer Filler System		 
	     Army Training Requirement and Resources		 
	     System						 								 
	     Defense Health Program				 
	     DOD Anthrax Vaccine Inoculation Program		 
	     DOD Chemical and Biological Defense		 
	     Program						 								 
	     DOD Defense Planning Guidance			 
	     DOD Joint Strategic Capabilities Plan		 
	     Total Army Analysis Process			 

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GAO-02-38
     
Report to the Chairman, Subcommittee on National Security, Veterans Affairs,
and International Relations, Committee on Government Reform, House of
Representatives

United States General Accounting Office

GAO

October 2001 CHEMICAL AND BIOLOGICAL DEFENSE

DOD Needs to Clarify Expectations for Medical Readiness

GAO- 02- 38

Page i GAO- 02- 38 Chemical and Biological Medical Readiness Letter 1

Results in Brief 2 Background 4 Scope and Methodology 8 DOD and the Services
Have Not Systematically Reviewed the

Adequacy of the Medical Specialist Mix for the Treatment of CB Casualties 9
Levels of Training, Testing, and Exercising for Medical

Management of CB Casualties Remain Low 19 Conclusions and Recommendations 36
Agency Comments and Our Evaluation 38

Appendix I Specific Signs, Symptoms, Diagnoses, and Treatment for Some
Common Chemical and Biological Agents 41

Appendix II General Distinguishing Features of Chemical and Biological
Terrorism 43

Appendix III U. S. Military CB Warfare Medical Training Summary Tables,
Fiscal Years 1997- 2000 44

Appendix IV Comments From the Department of Defense 46

Appendix V GAO Contacts and Staff Acknowledgments 49 GAO Contacts 49 Staff
Acknowledgments 49

Related GAO Products 50

Tables

Table 1: Military Officers and Enlisted Personnel Trained in Courses on CB
Medical Treatment, Fiscal Years 1997- 2000 22 Contents

Page ii GAO- 02- 38 Chemical and Biological Medical Readiness

Table 2: Fiscal Years 1997- 2000 4- Year Medical Personnel CB Warfare
Training Totals as a Percentage of Fiscal Year 2000 End Strength 26 Table 3:
Officers and Enlisted Personnel Trained in MCBC Courses,

Fiscal Years 1997- 2000 44 Table 4: Officers and Enlisted Personnel Trained
in FCBC Since

Fiscal Year 1999 44 Table 5: USAMRIID Biological Warfare Satellite
Broadcasts, Fiscal

Years 1997- 2000 44 Table 6: Military Health Service Total End Strength,
Fiscal Year

1999 45

Figures

Figure 1: Proficiency Measures From the Army Study Medical Training 2000,
Slide from Medic Training 2000 Briefing Presented by Major General James B.
Peake 29 Figure 2: Numbers of Planned CINC Exercises, Fiscal Years 1993-

2005 34

Page iii GAO- 02- 38 Chemical and Biological Medical Readiness Abbreviations

ASD- HA Assistant Secretary of Defense for Health Affairs CB chemical and
biological CBW chemical and biological warfare CBO Congressional Budget
Office CMRT Continuing Medical Readiness Training CINC Unified Commander in
Chief CREST Casualty and Resource Estimation Tool CUD Common User Database
DOD Department of Defense FCBC Field Management of Chemical and Biological
Casualties JCAHO Joint Commission on the Accreditation of Healthcare

Organizations JRCAB Joint Readiness Clinical Advisory Board JSCAP Joint
Strategic Capabilities Plan MAT Medical Analysis Tool MCBC Medical
Management of Chemical and Biological Casualties NBC nuclear, biological,
and chemical OEP Office of Emergency Preparedness PACOM U. S. Pacific
Command TAA Total Army Analysis THCSRR Total Health Care Support Readiness
Requirement USAMRICD U. S. Army Medical Research Institute of Chemical
Defense USAMRIID U. S. Army Medical Research Institute for Infectious

Diseases USFK U. S. Forces Korea WMD weapons of mass destruction

Page 1 GAO- 02- 38 Chemical and Biological Medical Readiness

October 19, 2001 The Honorable Christopher Shays Chairman, Subcommittee on
National Security,

Veterans Affairs, and International Relations Committee on Government Reform
House of Representatives

Dear Mr. Chairman: The U. S. strategy against chemical and biological (CB)
weapons is based largely on deterrence. In the event deterrence fails,
medical response planning will be essential. However, following the 1991
Gulf War, reviews that we and the Inspector General of the U. S. Department
of Defense (DOD) completed in 1992 and 1993 identified a number of
shortcomings in DOD?s capacity to provide medical support for the numbers of
contaminated casualties that were predicted, and in 1996 we found that many
of the problems identified in these reports persisted. 1 In the 10 years
since Desert Storm, DOD has implemented a mandatory immunization program for
anthrax, but, despite statements from defense officials emphasizing the
seriousness of these threats, questions remain about DOD?s overall medical
readiness for the full array of chemical and biological warfare threats that
have been identified. The attack on the United States, on September 11,
2001, underscores the need for medical readiness should deterrence fail.

You asked us specifically to determine how DOD has adapted its medical corps
to emerging CB threats. As we agreed with your office, our objectives in
this review were to assess (1) the efforts of DOD and the services to
incorporate CB threats in medical personnel planning and to

1 Operation Desert Storm: Full Army Medical Capability Not Achieved

(GAO/ NSIAD- 92- 175, Oct. 18, 1992); Operation Desert Storm: Problems With
Air Force Medical Readiness (GAO/ NSIAD- 94- 58, Dec. 30, 1993); Operation
Desert Storm: Improvements Required in the Navy?s Wartime Medical Care
Program

(GAO/ NSIAD- 93- 189, July 28, 1993); Chemical and Biological Defense:
Emphasis Remains Insufficient to Resolve Continuing Problems (GAO/ NSIAD-
96- 103, Mar. 29, 1996); and Inspector General, DOD, Medical Mobilization
Planning and Execution (93- INS- 13, Sept. 30, 1993).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 38 Chemical and Biological Medical Readiness

adapt its medical specialty mix accordingly and (2) the extent of medical
personnel training in the treatment of CB casualties.

Public assessments by defense officials have emphasized the seriousness of
the military threat from chemical and biological weapons. However, we found
that neither DOD nor the services have systematically examined the adequacy
of the current specialty mix of medical personnel for chemical and
biological defense. While some of the services have begun to review the
staffing of deployable medical units for the capacity to manage the
consequences of certain chemical warfare scenarios, they have not done so
for biological warfare scenarios. In general, DOD has not successfully
adapted its conventional medical planning to CB warfare. For example, the
software, evaluations, and review processes it used in medical planning did
not incorporate these threats as they did conventional ones, and they have
lacked the information on casualty rates or qualified care providers
required to address the appropriateness of the current mix of expertise and
competencies.

Although joint protocols for treating CB casualties have recently been
completed, as recommended by DOD studies, agreement has not been reached
among the services on which health care providers are appropriate to provide
treatment. DOD officials attributed the weakness of CB medical planning to
several factors, including failure to establish this as a medical priority
in Defense Planning Guidance (particularly for biological warfare), data and
methodological constraints that complicated the task, disagreements among
the services about the capacity to implement evacuation policy, and
pessimism that medical support could effectively treat substantial numbers
of CB casualties. Joint, unified command, and service planners charged with
addressing these issues all expressed frustration with inaction on the part
of others. In particular, the medical planners for the unified commands
stated that, in the absence of better planning support from the services,
they had reluctantly adopted a rough method of estimating the medical
support required for CB scenarios- applying a fixed multiplier to the
support required for conventional ones. This method presumes that the
individual medical units currently possess the appropriate mix of health
care providers.

Relatively few military health care providers are trained to a standard of
proficiency in providing care to CB casualties. Service medical planning
officials generally maintained that their medical units had to be prepared
to handle a broad range of casualties and that even specialists would have
to serve as generalists when they were in theater. They believed that
Results in Brief

Page 3 GAO- 02- 38 Chemical and Biological Medical Readiness

specialized military medical training was the appropriate way to address any
additional medical skills needed to deal with CB casualties rather than
adjusting the mix of health care specialists. However, while progress has
been made since the Gulf War in increasing the availability of such
specialized training, these courses are essentially voluntary. On the basis
of the number of students who have taken the various courses, we found that
no more than 19 percent of uniformed health services personnel had completed
any specialized CB military medical training. No more than 2.2 percent of
medical officers had completed the full 7- day course in the Medical
Management of Chemical and Biological Casualties. Even the individuals who
have been trained cannot be readily identified in the event of an emergency
because either the tracking systems do not exist or they are not currently
functioning. Except for the Army?s Medic 2000 study, which found that the
lowest proficiency scores among medics were for nuclear, biological, and
chemical (NBC) skills, the services have not rigorously tested proficiency
in assessing and treating CB warfare casualties. This study and other
indirect evidence indicate that proficiency is low, partly because of weak
or absent requirements for training, testing, and certification.

Although the service surgeons general have begun integrating chemical and a
few biological scenarios into their medical exercises, medical planners from
each of the five regional unified commands told us that to their knowledge
no realistic field exercise of medical support for chemical or biological
warfare had been conducted. Additional data provided by DOD showed that only
two joint military exercises planned since 1993 had included both medical
response and chemical or biological warfare. Similarly, key readiness
evaluations used to advise the President on readiness to implement the
national security strategy had never set a scenario for the unified
commanders requiring medical support for weapons of mass destruction.
Officials told us CB medical support is rarely exercised because of
conflicting priorities encountered by both warfighters and medical staff and
because it is very difficult and expensive.

In sum, DOD and the services had 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 consequence, medical readiness for CB scenarios cannot be ensured. The
persistence of this situation suggests a disagreement about the significance
of the threat, a failure of leadership, or an acceptance of a high level of
risk.

Page 4 GAO- 02- 38 Chemical and Biological Medical Readiness

We recommend that the Secretary of Defense 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, integrating chemical and biological medical readiness in
Defense Planning Guidance. To the extent that DOD continues to regard CB
threats as serious in its areas of operations and expects its medical forces
to prepare for them, the Secretary of Defense should require that the
services and joint staff agree on evacuation capacity and the medical
providers qualified to provide specific wartime care, develop joint planning
models that include CB scenarios, develop training requirements and assess
their effectiveness with proficiency metrics and standards, develop and
maintain the systems to track CB training and proficiency, and increase the
realistic exercise of medical support for both chemical and biological
scenarios. DOD has reviewed a draft of this report. It concurred with the
recommendations and provided additional comments.

DOD officials and U. S. government reports have stated that CB warfare must
be considered a potential threat in future conflicts. Any reshaping of the
military medical force to respond to CB threats would occur in a context
including (1) a broad variety of CB agents that could produce a range of
effects from minor irritations to mass casualties and (2) a dual medical
mission with tensions between the needs of day- to- day peacetime care and
wartime operations. Within these constraints, the joint staff of the Office
of the Secretary of Defense and the services play distinct but interrelated
roles in ensuring medical readiness. The tools available to them for this
purpose include various types of training and exercises.

In June 1995, Presidential Decision Directive 39 declared that ?the United
States shall give the highest priority to developing effective capabilities
to detect, prevent, defeat and manage the consequences of nuclear,
biological or chemical (NBC) materials or weapons use by terrorists.? The
former Secretary of Defense further emphasized at his confirmation hearing
in January 1997 that U. S. forces in theater face the threat of chemical and
biological weapons:

?I believe the proliferation of weapons of mass destruction presents the
greatest threat that the world has ever known. We are finding more and more
countries who are acquiring technology- not only missile technology- and are
developing chemical weapons and biological weapons capabilities to be used
in theater and also on a long- range basis. So I think that is perhaps the
greatest threat that any of us will face in the coming years.? Background

High- Level Officials Have Emphasized the Seriousness of CB Threats

Page 5 GAO- 02- 38 Chemical and Biological Medical Readiness

In 1998, the Chairman of the Joint Staff issued Master Plan Exercise
Guidance that identified NBC defense and force protection as his top
training issues, and DOD began its much- publicized Anthrax Vaccine
Inoculation Program. In fiscal year 2001, the budget for the Defense Health
Program, which includes financing for both peacetime and deployment care,
was approximately $18.2 billion. The President?s Budget Request for the
Chemical and Biological Defense Program was $836 million, an increase from
the $791 million in total obligations for fiscal year 2000. 2 The Defense
Health Program budget for fiscal year 2000 incorporated at least $137
million for medical training. 3 The Army Medical Department?s NBC Defense
Readiness Program uses about $17 million annually in operation and
maintenance funds to purchase countermeasures and provide supplemental
support for exercises and training of medical units for NBC.

Anticipating the medical personnel needs associated with chemical and
biological warfare is complicated by the wide array of such agents, the
differences in their effects, and the variety of ways they might be used.
The physiological effects of specific agents identified as potential threats
are extremely varied, as detailed in appendix I. In general, a chemical
attack would typically result in illness quickly, whereas biological agents
could result in illnesses with delayed onset. The distribution of victims
would usually be limited to the area downwind from a chemical attack but
could be more widely spread for contagious biological agents. First
responders to a chemical attack on a battlefield or in a war zone would be
soldiers, medics and corpsmen, but because of the delayed effects, the first
responders to a biological attack on military personnel in a war zone would
more likely be sick- call physicians. (See appendix II.)

Not only must medical personnel requirements be tailored to cover a variety
of potential threats; they must also be coordinated with the medical
personnel requirements of day- to- day care for military personnel,
dependents, and retirees. The military medical service has historically had

2 Fiscal year 2000 funding data are based on total obligation authority.
According to Army Medical Department officials, this is the source for most
CB warfare training funds. See DOD, Chemical and Biological Defense Program:
Annual Report to Congress, March 2000 (Washington, D. C.: 2000).

3 Additional amounts were used to support the Uniformed Services University
of the Health Sciences and to finance the Health Professional Loan Program
that provides scholarships to medical personnel in exchange for military
service. The Threat Is Composed of

Varied Agents The Dual Medical Mission Complicates Planning

Page 6 GAO- 02- 38 Chemical and Biological Medical Readiness

a dual mission- supporting the force during deployments and providing a
health care benefit to DOD personnel and their dependents. Some mismatch
naturally exists between the skills required by wartime and peacetime care.
4 For example, some of the services most used by DOD beneficiaries in
peacetime, such as obstetrical care, are not likely to be in high demand by
a deployed force. Military surgeons train for wartime inpatient care but
currently practice mostly outpatient and pediatric care. Similarly, the
skills required for responding to a chemical or biological attack may not be
naturally encompassed in the demands of a peacetime health care service.
This is important insofar as any skills that are uniquely required in
wartime must be sustained in the absence of much direct use. 5

Defense planning is led by the Office of the Secretary of Defense, which
sets overall policy and develops Defense Planning Guidance that is based on
the President?s national security strategy. Every 2 years, the Joint Chiefs
issue a Joint Strategic Capabilities Plan (JSCAP) based on this formal
guidance that gives missions to the nation?s unified combat commands which
have operational control of U. S. combat forces. Each command is headed by a
Commander- in- Chief (CINC). They are responsible for fighting and winning
the nation?s wars within a particular area of responsibility, usually
geographic. The CINCs develop war plans and requirements that specify the
combat troops that will be needed to meet the threat and mission assigned by
the JSCAP.

4 See W. M. Hix and S. Hosek, Elements of Change in Military Medical Force
Structure: A White Paper (Santa Monica, Calif. RAND, 1992), and
Congressional Budget Office,

Restructuring Military Medical Care (Washington, D. C.: July 1995). For
example, CBO reported that ?the care furnished in military medical centers
and hospitals in peacetime bears little relation to many of the diseases and
injuries that medical personnel need to be trained to deal with in wartime.?

5 The services have handled this mismatch historically by developing
substitution rules to determine which peacetime specialties can be employed
to fulfill the various wartime medical needs. For example, the Navy permits
obstetricians to fill certain field surgical positions because it must meet
the need for fully qualified obstetricians in peacetime, and Navy medical
officials told us that these specialists are familiar with basic abdominal
surgery. However, the risk of such substitutions is not clear, and service
officials identified no formal process for determining their effect on
standards of care. Recognizing that not all physician specialties are
substitutable, a study of medical requirements by DOD?s Office of Planning,
Analysis, and Evaluation recommended a follow- on effort to determine the
mix of physician skills required to support the wartime effort, in order to
ensure that adequate care is provided. See DOD, Office of Planning,
Analysis, and Evaluation, 733 Update Wartime Medical Report (Washington, D.
C.: July 24, 1997), p. ESii. Department, Joint Staff,

and Services Play Different Roles in Ensuring Medical Readiness

Page 7 GAO- 02- 38 Chemical and Biological Medical Readiness

Each service then calculates the additional number of troops it will need to
support the combat force. The total number of combat and support troops
determines the military population at risk. On the basis of the threat, the
population at risk, and previously developed doctrine, the service medical
planners project the required hospital and unit assignments. Each of the
services has the responsibility to work within the budget identified by DOD
to train and equip its forces and to staff the needs identified by the
CINCs. Specifically, in the context of medical readiness, the services are
responsible for ensuring that individuals and units can perform the
functions (such as medical assistance) to which they are assigned.

The CINCs then review the services? plans for filling their needs. For
example, a CINC medical planner would review the adequacy of service
components? plans for medical support and would integrate their logistical
requirements. The Joint Staff helps the CINCs resolve any readiness problems
discovered in the context of the Joint Monthly Readiness Review or through
other means. Any systemic problems or shortfalls in readiness the CINCs note
are brought to the attention of the joint staff for medical planning (J4),
which works to resolve them. Finally, DOD finances the services and reviews
service expenditures (including those on medical personnel and services).

The services and CINCs address their responsibilities to ensure readiness
partly through training and exercises. Training can be provided either to
individuals or units, and exercises are of several types, including (1)
tabletop exercises that test decision making in response to a single
problem; (2) command post exercises, in which multiple decision makers
respond to dynamic scenarios; and (3) full field exercises, in which
opposing armies compete to simulate a range of activities from combat to
medical response. Tabletop and command- post exercises are useful to the
extent that they identify important policy and operational issues, but they
do not demonstrate actual ability to provide effective medical care in a
forward setting. Field exercises may be further divided, based on the
specific capabilities they are intended to test, such as the ability to
detect agents and quickly don protective gear, the ability to function in
protective gear, or the ability to decontaminate exposed personnel.
(Decontamination is not a doctrinal responsibility of medical units,
although they may, in practice, be required to perform it.) Our focus was on
exercises that test the ability of medical units to correctly diagnose and
treat symptomatic patients.

Page 8 GAO- 02- 38 Chemical and Biological Medical Readiness

To assess the efforts of DOD and the services to adapt their medical
specialty mix to CB warfare threats, we examined medical personnel planning
processes, interviewed medical planners, and reviewed studies of medical
requirements. We also reviewed literature and interviewed experts in the
treatment of CB- related injuries and diseases.

To assess the extent of medical personnel training in the treatment of CB
casualties, DOD?s ability to track who has been trained, and the extent of
proficiency testing and readiness exercises, we interviewed service trainers
and medical administrative officers regarding related training requirements,
the availability of training opportunities, and the portion of medical
personnel who had completed such training. We also questioned medical
planners from the unified commands and queried the joint exercise planning
database regarding exercises incorporating both medical components and
chemical or biological warfare. We reviewed the use of CB threats in medical
personnel planning and compared it to the stated threats and to methods used
to plan, train, exercise, and test the readiness and proficiency of medical
support for conventional warfare as well as methods the Office of Emergency
Preparedness uses to develop better trained medical personnel for domestic
response to disasters, including CB agents.

Specifically, we conducted interviews with the Office of the Secretary of
Defense for Health Affairs, the Office of Program Analysis and Evaluation,
and Joint Medical Planning Staff. We met with planning and training
officials at the Army Medical Department at Fort Sam Houston, the Navy
Surgeon General?s Office, the Navy Bureau of Medicine and Surgery, and the
Air Force Surgeon General?s Staff at Bolling Air Force Base. We attended the
annual Association of Military Surgeons and the Weapons of Mass Destruction
2000 meetings. We also met with officials of the Joint Readiness Clinical
Advisory Board, the U. S. Army Medical Research Institute of Infectious
Diseases, and the U. S. Army Medical Research Institute for Chemical
Defense. We attended meetings between the unified command medical planners
and Joint Medical Planning Staff (J4), and we conducted follow- on
interviews by phone and e- mail.

Our inquiry was limited to medical personnel planning and training for CB
threats. The scope of our work covered active duty and reserve medical
personnel planning and training by the Army, Navy, and Air Force; we did not
separately examine the Marines, for whom the Navy provides medical support
and personnel. Our focus was on medical readiness to support the armed
forces in the event of chemical or biological warfare agent exposure in
areas outside the United States. Although we conducted some Scope and

Methodology

Page 9 GAO- 02- 38 Chemical and Biological Medical Readiness

interviews with the Office of Emergency Preparedness to examine its approach
to medical personnel planning for CB consequence management, we did not
focus on DOD?s support of domestic preparedness efforts. Similarly, we did
not explicitly test alternative theories regarding the cause of the current
planning and training conditions, although we asked DOD officials for their
analysis of the underlying causes. We conducted our study in accordance with
generally accepted government auditing standards between December 1999 and
April 2001.

While some of the services have begun to review the staffing of deployable
medical units for the capacity to manage the consequences of certain
chemical warfare scenarios, they have not done so for biological warfare
scenarios. Similarly, DOD?s efforts to assess medical requirements, and CINC
and joint staff efforts to develop and review war plans, have not addressed
CB scenarios as they have conventional ones, and joint medical planning
tools lack the ability to do so. CB warfare planning failures were
attributed to service disagreement about evacuation capability, which
personnel were qualified to provide treatment, and the inherent difficulty
of such planning. In addition, with respect to medical planning for
biological warfare defense, service officials cited the absence of direction
in the Defense Planning Guidance. In the absence of effective formal
planning, combat medical planners expressed concern that they can make only
an educated guess about CINC requirements for specific medical personnel in
the event of a chemical or biological attack. Medical planners stated that
the planning process currently lacks the capability to adequately estimate
medical requirements in the event of chemical or biological warfare.

Each service determines its medical personnel requirements by using one or
more models that predict the number and nature of casualties that would
ensue from scenarios incorporated in current Defense Planning Guidance.
However, service officials stated that these scenarios have not included
biological warfare. In addition, the services varied in the nature and
status of their efforts to incorporate chemical warfare in medical personnel
planning. The service- based efforts were largely reviews of the DOD and the
Services

Have Not Systematically Reviewed the Adequacy of the Medical Specialist Mix
for the Treatment of CB Casualties

Service Methods for Personnel Planning Do Not Specify the Personnel Required
to Manage CB Casualties

Page 10 GAO- 02- 38 Chemical and Biological Medical Readiness

staffing of medical units rather than more thorough reviews of the medical
force structure. 6

For example, the Army is DOD?s executive agent for CB warfare support. Yet
Army officials stated that its medical structure, Medforce 2000, was
primarily based on cold war scenarios that assume many serious traumas
requiring surgical care, a high rate of fatalities, and few cases of
nonbattle injury and disease. 7 The Army force structure is planned through
a biannual assessment of the Army?s future requirements, known as the Total
Army Analysis (TAA). The Army Medical Department identifies the medical
personnel and equipment required to support the force in the combat
scenarios used in the TAA, determines the composition of medical teams, and
recommends an appropriate workload. 8

Based in part on the TAA for 2005, the Army estimated the additional number
of beds that would be needed to cope with casualties from a chemical attack
but did not analyze the specific skill mix needed. Following Defense
Planning Guidance, TAA had not incorporated biological warfare scenarios.
Army Medical Department officials indicated both that they were not
authorized to structure medical care for biological contingencies and that
battlefield CB scenarios causing mass casualties would overwhelm current
medical capabilities. Not until 1998, for TAA for 2002 through 2007 did the
Army fully integrate general medical requirements and begin to use chemical
casualty scenarios (involving a liquid nerve agent and mustard) to drive
force requirements. To support a periodic adjustment of rank structure
within particular specialties, the Army is reviewing 39 medical staff
functions to assess whether the need for them has changed. 9 Army officials
told us that it would take about 3

6 All the service medical planners are constrained by existing structures,
including medical centers, field hospitals, hospital ships, and mobile
hospitals, and important parts of their planning processes concern decisions
about how best to staff these units.

7 Army medical officials told us that, during the Gulf War and in Bosnia,
this emphasis on surgical capability meant that medical units did not have
the right specialty mix for the general medical illnesses they encountered
at sick call.

8 Specifically, the Army applies its Patient Generator Model to estimate
casualty rates, using the same patient condition categories as the Medical
Analysis Tool (MAT) but with more detailed specification of patient data.
Then the Army uses these data to determine essential medical personnel
requirements.

9 Such reviews had been completed for podiatry, patient holding services,
hospital litter bearers, veterinary animal care, and ear, nose, and throat
services. Functions such as respiratory care, which could be affected by the
introduction of chemical agents, were reviewed just before the new TAA and
are not likely to be revisited for another 2 or 3 years.

Page 11 GAO- 02- 38 Chemical and Biological Medical Readiness

years to complete this process for all medical functions. They explained
that under the present planning system, the number of billets for particular
medical specialties is based largely on the historical staffing of Army
treatment facilities. 10

Similarly, according to the Navy, its medical requirements are not directly
set or affected by CB warfare scenarios. Navy medical planning efforts rely
primarily on analyses and methods such as DOD?s 733 Update report, the Total
Health Care Support Readiness Requirement (THCSRR) model for developing
medical requirements, and the Medical Analysis Tool (MAT), which have
limited utility for planning a medical specialty mix for CB warfare. The 733
Update projected an upper bound for the number of beds required in support
of a chemical scenario, not a biological one, and included no findings with
respect to the nature of the personnel required. The MAT- medical planning
software approved by the joint staff and used extensively by the Navy for
planning and current operations- lacks treatment protocols, casualty rates,
and bed requirements necessary to model specialty mix for CB warfare. Thus,
the Navy has not identified the specific personnel mix required to treat
casualties exposed to CB warfare agents. Without specific casualty rate
estimates for chemical contingencies, Navy medical planners estimate medical
personnel requirements for chemical contingencies by increasing the estimate
for conventional conflict by a specified percentage. 11

The Air Force, like the Army, determines the expected distribution of
patients by condition and severity and then matches unit types to this
workload to arrive at personnel requirements. The Air Force also
periodically reviews medical unit composition. It has reviewed its array of
medical units and has added units for infectious diseases, theater
epidemiology, and preventive aerospace medicine within the past 3 years.

10 Another hindrance to planning medical requirements for CB scenarios has
been the lack of agreement on treatment protocols for injuries and illnesses
attributable to CB exposures. These protocols were not completed by the
Joint Readiness Clinical Advisory Board (JRCAB) until early 2000, too late
to incorporate in this planning cycle.

11 The Army has developed and is testing a new model, the Casualty and
Resource Estimation Tool (CREST), for estimating CB warfare casualties and
bed requirements. CREST is a plume model that can estimate need for various
types of beds but cannot determine need with respect to specific expertise
or skill mix. Although CREST will provide a means of estimating CB warfare
casualties and bed requirements that MAT lacks, some joint medical planners
were critical of the model because it was not developed jointly and because
casualty rates can be highly sensitive to variations in assumptions. For
specific scenarios analyzed with CREST, casualties ranged up to 500, 000.

Page 12 GAO- 02- 38 Chemical and Biological Medical Readiness

Air Force medical planners indicated that they were challenged to keep up
with the workload associated with predeployment examination and
immunization. However, officials told us they had not adjusted Air Force
medical units and personnel for biological warfare. Air Force officials
volunteered that mass casualty scenarios would inevitably cause bottlenecks.
12 In addition, they noted that medical requirements are quite sensitive to
presumed rates of evacuation and that the Army and Air Force do not agree on
the rates that would be achievable. 13

While maintaining that the current specialty mix is generally appropriate to
these emerging threats, service planners did identify additional skills that
would be key to successful medical management of CB warfare casualties. Some
Army officials expected that chemical warfare readiness would require an
increase in respiratory therapy, ward nursing, and internal medicine. Others
noted that the Army did not have a lot of infectious disease experts in
deployed hospitals for surveillance and prevention. Similarly, Air Force
officials expected that chemical warfare scenarios would require more
respiratory technicians, pulmonologists, critical care nurses, and intensive
care beds. They stated that the threat of biological warfare would increase
the need for infectious disease and preventive medicine personnel as well as
personnel to collect baseline, predeployment data. Air Force and Navy
medical planners both anticipated that chemical scenarios would require more
emergency personnel who could recognize and respond to symptoms quickly.
(See appendix II.) Although these informal assessments varied, they implied
that the current specialty mix needed revision.

DOD?s tools for planning medical requirements are highly structured and
scenario dependent, and the possibility of CB warfare presents a large
variety of potential scenarios and weapons. Many of the tools and studies

12 For information on service medical requirement models, see Defense Health
Care: TriService Strategy Needed to Justify Medical Resources for Readiness
and Peacetime Care

(GAO/ HEHS- 00- 10, Nov. 3, 1999). 13 Several Army officials were skeptical
about Air Force capacity to evacuate at the rates required and stated that
the Army had not complied with the joint planning guidance based on these
concerns. Army officials were skeptical that the Air Force?s Critical Care
in the Air plan would work in mass casualty situations. Air Force officials
noted that the Army?s medical requirements were highly sensitive to
assumptions about the speed with which patients could be evacuated: Quicker
evacuation drastically reduces the estimated need for medical personnel in
the field. Medical Planning Methods

Have Not Been Adapted to CB Warfare

Page 13 GAO- 02- 38 Chemical and Biological Medical Readiness

for planning conventional medical response lack features required to
adequately plan for CB support or to assess the effect of CB warfare on the
appropriate mix of medical specialties. The services also could not agree on
which health care providers should implement joint treatment protocols.

CB warfare casualty estimation is highly complex and scenario- dependent and
therefore requires the consideration of many and varied factors. In
addition, the results can be highly sensitive to minor variations in some
assumptions. Potential biological warfare agents include anthrax, botulinum
toxins, viral encephalitis, enterotoxins, hemorrhagic fevers, plague, Q
fever, smallpox, and tularemia. 14 Once a specific agent is known, the
method and quantity in which it is weaponized and delivered are just two
factors that can determine the kinds of resulting injuries and illnesses.
Additionally, the population at risk and troop configuration, where the
weapon hits relative to the population, the intensity of the conflict, the
likely air stability, humidity, temperature and sunlight, warning times, the
availability of protective equipment, and evacuation rates all potentially
affect exposure, casualty and medical workload rates. With more than a dozen
highly variable factors at play, casualty estimates can and do vary from
zero to more than half a million. Casualties could appear immediately or
much later at sick call and in hospitals. They may need simple
decontamination or they may be contagious. They may need to be evacuated or
they may need to be isolated. A precise planning process based on highly
specific scenarios may be challenged by a range of scenarios this broad and
uncertain.

Faced with similar issues and uncertainties, for instance, the Office of
Emergency Preparedness (OEP) takes a more qualitative approach to focus its
personnel planning efforts on ensuring a highly flexible response. OEP
officials stated that there are so many variables that it would be
impossible to predict casualties and mold a response. Instead, they plan for
a range of scenarios, from the relatively easy to mass casualty scenarios
involving thousands of cases. However, a flexible response is predicated on
the existence of adequate numbers of well- trained personnel and teams that
can be mobilized. OEP is supporting efforts to identify the

14 D. R. Franz and others, ?Clinical Recognition and Management of Patients
Exposed to Biological Warfare Agents,? Journal of the American Medical
Association, 278: 5 (1997), 399- 411. Precise Medical

Requirements Planning Confronts a Broad and Uncertain Range of Scenarios

Page 14 GAO- 02- 38 Chemical and Biological Medical Readiness

core competencies needed among physicians, nurses, and emergency medical
technicians and to encourage their incorporation in standard board
certification.

Compounding these problems, DOD officials characterized data on chemical
warfare casualty rates as limited and generally dated. They stated that most
of the available data were derived from warfighting and medical care as
practiced during World War I. These rates might be lower in today?s more
mobile, highly dispersed warfighting. For more novel agents, even historical
data are unavailable.

Similarly, while DOD experts believe that very good data are available on
the effects of biological agents once the nature and extent of exposure are
known, they stated that generally little was known about the exposures that
would result from weaponized agents. Computer models can help generate
estimates for purposes of testing their sensitivity to a range of
assumptions, but validating many of the assumptions may not be possible.

Two major reviews of medical personnel requirements were completed by DOD?s
Office of Program Analysis and Evaluation (PA& E) in the 1990s. Section 733
of the National Defense Authorization Act for Fiscal Years 1992 and 1993
directed the Secretary of Defense to conduct a comprehensive study of the
military medical care system required to support the Armed Forces during a
war or other conflict. 15 DOD completed the study and in April 1994 issued a
final report to the Congress, The Economics of Sizing the Military Medical
Establishment: Executive Report of the Comprehensive Study of the Military
Medical Care System,

generally known as the 733 Report. In August 1995, PA& E was directed to
update the report?s estimates to reflect changes in force levels and
planning scenarios and to better include rotational and training
requirements. This study, the 733 Update, was completed in May 1999. Both
reports found that DOD had programmed far more physicians than were needed
for the wartime missions associated with two nearly simultaneous regional
conflicts. 16 Although the Office of Program Analysis and Evaluation
approved the 733 Update, DOD never issued it because the Air Force disputed
the results. The Air Force maintained that the physician level recommended
was too low because it did not reflect recent

15 Pub. L. No. 102- 190, National Defense Authorization Act for Fiscal Years
1992 and 1993. 16 In July, 2001, DOD dropped the two nearly simultaneous
regional wars scenario as the principal basis for military planning. DOD
Evaluations of Medical

Requirements Have Not Fully Assessed CB Scenarios and Lacked Data for
Assessing Specialty Mix

Page 15 GAO- 02- 38 Chemical and Biological Medical Readiness

joint guidance that expanded Air Force support of humanitarian civil
assistance and disaster requirements.

Neither the original 733 Report nor the update fully assessed the medical
requirements for CB warfare threats. In the absence of a standard
methodology for estimating theater casualties from such weapons, the 733
Update was based on a conventional conflict with a major excursion used to
estimate chemical casualties. The separate chemical warfare scenario based
on the results of the Joint WMD Analysis was used to estimate medical
workload. 17 However, the scenario expected after the release of an aerosol
cloud of a biological agent would be quite different.

The 733 Update?s review of workload requirements was based on an analysis of
conflict scenarios from the Defense Planning Guidance (to generate possible
casualty streams) in conjunction with medical planning factors (such as
evacuation policy, dispersion factors, and the average lengths of hospital
stay). The authors of the updated study cited a lack of approved data on the
care requirements of victims of NBC agents and noted that the study relied
instead on the expert opinions of several military medical professionals to
generate estimates. The study recommended DOD charter a medical panel to
review various agents and their associated health effects and medical
requirements for future DOD planning. The Joint Readiness Clinical Advisory
Board was given this assignment.

The 733 Update used the methodology developed for the original study to
identify the total number of physicians required but recognized that ?not

all physician specialties are substitutable.? The study concluded that ?the

current manning policy for deployable hospitals varies greatly from the?
identified 733 requirements for surgeons and other specialties.? 18 In
addition, the updated study found that the care factors necessary to

17 DOD, Joint WMD Analysis (J- 8) (Washington D. C.: 1997). 18 The analysis
established requirements for facilities (surgical and medical beds,
operating rooms) and physicians at each echelon of care, including medical
facilities in the continental United States. It also developed estimates of
peak loads for intra- and intertheater medical evacuations, recommended an
active- reserve component mix that minimized the number of active duty
personnel required, and compared projected intratheater care requirements
against the wartime capabilities currently programmed for specific theaters.
The analysis did not review the organization or staffing of patient hospital
care and basic medical units, and it did not review their ability to provide
required medical care.

Page 16 GAO- 02- 38 Chemical and Biological Medical Readiness

identify needs by physician specialty were last reviewed in a 1988 study.
The 733 Update?s first recommendation was that ?A follow- on study should be
undertaken to update the common- use care factors and determine the
appropriate mix of physician specialties needed to support the wartime
requirements in deployable hospitals.? 19 Officials of DOD?s Office of
Program Analysis and Evaluation told us that they did not know if any action
had been taken on this recommendation that a study of physician specialty
mix be conducted.

We found that the Joint Staff lacked functional tools for planning medical
needs for CB warfare and that as a consequence, CINC medical planners were
concerned they could make only educated guesses regarding these needs. The
Medical Analysis Tool (MAT)- software CINCs use to identify medical
requirements, review war plans, assess the sufficiency of service support,
and develop schedules for deploying medical personnel and equipment to the
theater of war- has lacked capability to support planning for the risks of
CB warfare. This is significant in part because the MAT is the only tool the
Joint Staff has approved for medical planning. The MAT uses casualty rates,
patient types, and specific treatment protocols to project medical
requirements- that is, admissions, evacuations, and beds required. When we
reviewed the progress of CB medical planning, the MAT had neither
incorporated profiles identifying the types of injuries and illnesses CB
attacks would generate nor the treatment protocols these injuries and
illnesses would require. Booz- Allen Hamilton, the contractor responsible
for the MAT planning tool, was taking steps to incorporate CB treatment
protocols developed by the Joint Readiness Clinical Advisory Board
(discussed below), but the services have not agreed on the medical personnel
who are qualified to treat patients with these protocols.

In addition, the medical planners at the CINCs, who do the day- to- day
medical readiness planning, voiced strong concerns about the adequacy of
service planning for CB and stated that they had neither appropriate warfare
planning factors nor service- approved casualty rates with which to estimate
medical requirements. 20 In the absence of this information,

19 733 Update Wartime Medical Report, Executive Summary, p. ES- ii. 20 While
the Center for Army Analysis has conducted a joint study of chemical warfare
casualty rates, this was performed for the purposes of estimating protective
equipment needs and did not include the level of detail about specific types
of casualties required for determining medical personnel needs. Joint
Medical Planning Lacks

the Capability to Determine Medical Personnel Needs for CB Warfare

Page 17 GAO- 02- 38 Chemical and Biological Medical Readiness

medical planners stated that they estimated CB medical requirements by using
a rule of thumb: They supplemented the estimated number of medical personnel
required for conventional warfare with an additional percentage to cover the
undetermined medical need in the event of CB warfare. However, this method
assumes that the medical requirements for CB support would exceed those of
conventional war but would not differ qualitatively. Both the Joint Staff
for Medical Readiness and the theater medical planners recognized that this
estimation method was neither precise nor well validated.

The Joint Staff for Medical Readiness reviews the estimates the CINC
planners produce without examining the mix of specialists. This suggests a
limited ability to conduct joint medical planning for CB scenarios. The
Joint Staff officials stated that they were reluctant to accept a CB
planning model unless the operations, intelligence, and WMD communities had
fully approved it.

The Joint Readiness Clinical Advisory Board (JRCAB) was assigned to act on
the 733 Update recommendation to develop treatment protocols for injuries
and illnesses associated with CB warfare. It oversaw the creation of
separate CB expert panels that recently completed 22 treatment protocols for
patient conditions that could result from biological warfare and 20 for
chemical warfare. The protocols include type of injury, type of treatment
facility needed, bed requirement, patient length of stay by specific bed
type, and specific treatment requirements (e. g., lab tests) for each level
of care. The task was given to JRCAB because it had already been charged
with the larger task of further standardizing medical systems for war and
peacetime operations in support of a joint approach to medical planning. In
particular, it was charged with developing a Common User Database for MAT
and future medical modeling tools that would specify for each patient
condition the treatment required, the time required to provide the
treatment, and the personnel who should provide it. Without a common, up-
to- date database using current clinical protocols, all the service medical
models use different assumptions about the treatment needed, and the results
are neither comparable nor readily defensible.

JRCAB officials reported that achieving service agreement on treatment
providers was the most contentious issue they encountered; the advisory
board eventually had to settle for agreement on generic providers with links
to service specifics. Officials told us that the issue was that the
services, particularly the Army, did not want to give up flexibility in
deciding who would provide treatment in the field. Therefore, the ability to
The Services Lack Consensus

on Which Health Care Providers Should Implement Joint Treatment Protocols

Page 18 GAO- 02- 38 Chemical and Biological Medical Readiness

use these protocols to efficiently plan joint specialty mix requirements
will continue to be limited for both conventional and CB warfare.

In sum, although some progress has been made, DOD has not fully assessed the
effect of emerging CB threats on its overall medical personnel or specialty
mix requirements. CB medical planning is complicated by several factors, and
the weaknesses we observed had several potential causes. First, as in
conventional planning, planners are constrained by a dual mission, existing
medical facilities, and current force structure. Second, some methodological
constraints are more particular to CB planning: Pertinent data are limited
and often dated; CB casualty estimation is highly complex and scenario-
dependent and the results can be highly sensitive to minor variations in
assumptions; computer models can help generate these estimates, but
validating the underlying assumptions is not always possible. Third, Army
officials told us that no direction had been given in the Defense Planning
Guidance to plan medical support for biological warfare scenarios- even
though biological warfare scenarios are different than those for chemical
warfare. 21

Officials stated that exercises incorporating a more realistic, larger
number of casualties would overwhelm current systems and medical
capabilities. However, without realistic planning and exercises, being
overwhelmed by an actual CBW attack is all the more likely. In addition,
contentious issues such as the adequacy of medical personnel mix or the
appropriateness of evacuation plans may never be resolved without data from
credible exercises.

Over and above these constraints, joint, CINC, and service planners all said
they were constrained by lack of agreement or inaction on the part of

21 This mirrors the trend in civilian preparedness. According to D. A.
Henderson, Johns Hopkins Center for Civilian Biodefense Studies: ?Of the
weapons of mass destruction (nuclear, chemical, and biological), the
biological ones are the most greatly feared, but the country is least well
prepared to deal with them. Virtually all federal efforts in strategic
planning and training have so far been directed towards crisis management
after a chemical release or an explosion?. This exercise is not unfamiliar.
Spills of hazardous materials, explosions, fires and other civil emergencies
are not uncommon events. The expected scenario after release of an aerosol
cloud of a biological agent is entirely different?. Public health
administrators would be challenged to undertake emergency management of a
problem alien to their experience and in a public environment where
pestilential disease, let alone in epidemic form, has been unknown.? D. A.
Henderson, ?The

Looming Threat of Bioterrorism,? Science, 284: 5406 (Feb. 26, 1999).

Page 19 GAO- 02- 38 Chemical and Biological Medical Readiness

others. Service planners stated that they could not plan for biological
warfare defense if it was not included in the Defense Planning Guidance.
Joint Staff officials stated that they were reluctant to push CB planning
without an assessment tool that the operations, intelligence, and WMD
communities had fully approved. Although the approved joint planning tools
had yet to incorporate CB medical response, an NBC casualty estimation tool
the Army developed was being resisted by CINC medical planners, who stated
that they had not been involved in its development. Joint planning has been
further slowed by service disagreements on the key issues of who is
qualified to provide specific treatments and what evacuation capabilities
will be provided. In the end, the continuing disagreements would seem to
reflect a lack of high- level consensus and leadership.

Several sources suggest that the effect of these planning shortfalls is that
the current mix may be wrong. The 733 Update concluded that the current
manning policy varies greatly from the 733 identified requirements for
surgeons and other specialties. More recently, RAND documented a command-
post exercise that found that the Assistant Secretary of Defense for Health
Affairs ?must . . . redesign the medical facilities and force structure to
meet CBW medical requirements, as their current focus, on trauma surgery in
war, will not respond well to CBW casualties.? 22 Finally, even in the
absence of changes in formal planning, medical planners within all three
services informally anticipated a variety of specific changes needed in
specialty mix to adequately address CB scenarios. However, Army medical
planners said the need for specialized CBW skills should be met through
training rather than by specialty mix adjustment.

Although medical personnel generally receive instruction in such matters as
donning chemical protective gear, only the Army includes an introduction to
CB casualty management in basic training for medical staff. Specialized
courses have been developed and are available in various formats. However,
specific training to manage and treat CB casualties is effectively
voluntary, funding is unstable, and relatively few providers are trained.
The services also lack or do not use information systems for tracking
personnel who complete the training, and they do not conduct regular
standardized proficiency testing, even among the medical

22 Desert Breeze 5: Responding to WMD Threats in the CENTCOM AOR (Santa
Monica, Calif.: RAND NDRI, March 2000), p. xiv. Levels of Training,

Testing, and Exercising for Medical Management of CB Casualties Remain Low

Page 20 GAO- 02- 38 Chemical and Biological Medical Readiness

personnel who would have early contact with potential CB casualties.
Although the service surgeons general have begun integrating chemical and a
few biological scenarios into their medical exercises, they remain extremely
rare.

The Army, Navy, and Air Force require medical personnel to receive some
familiarization with personal protection for NBC environments. Each Army
corps, including the Medical Corps, does its own basic training. Enlisted
personnel who will become medics take 8 hours of NBC training as part of
their Initial Entry Training course, which is 10 weeks long. Army Medical
Department officials said the course trains to the minimum acceptable skill
level because of the cost of training so many people. Army officials stated
that they were developing a longer basic training program for medics but
could not yet fund it. 23 All new Medical Corps officers (physicians,
physician assistants, and nurses) take a 12- week basic course that includes
39 hours of NBC training. They are also required to take the Army Medical
Department Officer Advanced Course, which includes 10 hours of additional
NBC instruction as part of an 8- week correspondence course.

All Navy field hospital personnel are required to learn decontamination
procedures and receive familiarization training in how to function in a
chemically and biologically contaminated environment. However, Army Medical
Department officials observed that this is just- in- time training and meant
that many Navy trainees coming to their programs had not had the
prerequisite training in donning protective gear that all Army trainees
complete in their initial training. Navy officials said that they were
unaware of any such problem.

All Air Force Medical Service personnel are required to take some basic NBC
defense training annually. However, in the past, both its subject matter and
duration were left to the individual installation commanders, and Air Force
officials indicated that as a result, the training has varied from post to
post. New guidance has specified that this will be a 1- day course covering
the basics of NBC treatment, donning protective gear, and performing basic
mission functions while wearing the gear. The Air Force

23 Like the medics, Army medical junior noncommissioned officers receive a
basic course with 8 hours of NBC training. A few noncommissioned officers go
on to take the Army Health Physics Specialty Course, which includes some
additional NBC training. Some Basic Training

Includes Personal Protection and Very Basic CB Warfare Medicine

Page 21 GAO- 02- 38 Chemical and Biological Medical Readiness

has refocused the available training on the mobile medical personnel most
likely to need it. Others will continue to get the training on a just- in-
time basis.

In addition to the services? training efforts, the Defense Medical Readiness
Training Institute administers a triservice medical readiness program. Its
Combat Casualty Care Course for junior officers, medics, and first
responders is a 9- day course with 8 hours of NBC training. Institute
officials told us that the Army requires all medical personnel to take this
course but the Navy and Air Force do not. For staff in units that provide
definitive care, the Institute also offers a combat casualty management
course with a small NBC component.

The Army?s principal unit for training health care professionals in the
principles of chemical casualty care is the Chemical Casualty Care Division
of U. S. Army Medical Research Institute of Chemical Defense (USAMRICD),
which operates under the sponsorship of the Army Medical Department Center
and School. The Operational Medicine Division of the U. S. Army Medical
Research Institute for Infectious Diseases (USAMRIID) at Fort Detrick is the
Army?s principal authority on biological casualty care. Medical Management
of Chemical and Biological Casualties (MCBC) is taught by both centers
jointly. 24 It was designed primarily for physicians but is open to
physician assistants and nurses and, with permission, to senior medics and
medical service corps officers of all three armed services.

The 6- 1/ 2 day MCBC course provides familiarization with the principles,
management, and treatment of CB warfare injuries in combat. It includes
lectures from expert researchers, with both clinical laboratory and handson
field training. It is the only CB warfare medical course that meets the
criteria for entry on an officer?s permanent record, the Officer Record
Brief, and the only one that the Army Training Requirements and Resources
System tracks. According to Army training officials, this course had 280
slots per year until 1998 and was heavily subscribed with waiting lists,
when it was doubled to up to 560 slots. In the 4 years between 1996 and
2000, a total of 1,375 service medical personnel (including physicians,
physician assistants, nurses, and medics) took the on- site MCBC course.

24 Before 1992, each ran its own training course, but the two courses were
combined after the Gulf War. A Range of Specialized CB

Warfare Medical Courses Has Been Developed

Page 22 GAO- 02- 38 Chemical and Biological Medical Readiness

(See table 1.) A disproportionate number of these were from the Army. The
Army has about 52 percent of service medical corps personnel but 68 percent
of the MCBC on- site trainees. 25

Table 1: Military Officers and Enlisted Personnel Trained in Courses on CB
Medical Treatment, Fiscal Years 1997- 2000

Course Days training Army Navy Air Force All

services

MCBC on- site 7 929 330 116 1,375 MCBC off- site 3 4, 201 394 1,288 5,883
FCBC on- site 5 724 71 13 808 FCBC off- site 3 668 1 17 686 Biological
Warfare Satellite Course 1.5 6, 863 3,177 12,617 22,657 Chemical Warfare
Satellite Course 1.5 1, 692 371 1,524 3,587 Navy CBRE Familiarization 1 2,
337 2,337 Navy CBRE Casualty Management 3 463 463

Total 15,077 7, 144 15,575 37,796

To better meet the demand for course information beyond the limited slots
available, the institutes have pursued other, less thorough training
options. During Operation Desert Shield, they developed emergency courses
that grew into an exportable off- site version of the medical management
course pared down to 3 days of training, with the biological care portion of
the class cut from 3 days to half a day. Army personnel again made up
twothirds of those trained. The Air Force has shown far more interest in
offsite training than the Navy (1,288 compared with 394).

As more combat medics asked to take the medical management course, the
Institute of Chemical Defense tailored a course for them. In fiscal year
1999, it began the new course, Field Management of Chemical and Biological
Casualties (FCBC), whose purpose is similar to that of the medical
management course but which is less clinically intensive and has more
emphasis on early care in the field. The focus is on prehospital emergency
treatment and casualty decontamination. It is offered four times a year, and
a reduced off- site version is also available. For both

25 Some of the remaining slots go to civilian personnel.

Page 23 GAO- 02- 38 Chemical and Biological Medical Readiness

versions of the course, 1,494 military personnel have taken the class, all
but 102 of whom were Army trainees.

Because the demand for this training had not been met by the resident and
exportable courses, several distance learning programs were developed to
offset the shortfall:

 In September 1997, the Army?s Institute for Infectious Diseases offered
its first satellite class on the medical management of biological
casualties. The live satellite video teleconference on biological casualty
care comprised 3 half- days of broadcast material. In 4 years, 22,657
military health service officers have taken these courses, but attendance
peaked in 1998 when, for the first time, the Air Force required all medical
staff to take minimum NBC training and approved this course as meeting the
requirement. (See table 1 and more detail in appendix III, table 5.) Nearly
8,000 Air Force personnel registered for the course in the year of the
directive.

 In April 1999, the Institute of Chemical Defense followed with a course
titled Medical Response to Chemical Warfare and Terrorism. Among the
reported worldwide audience of from 2 million to 3 million people estimated
to have viewed at least part of the broadcast, 3,587 military personnel
registered for the course.

 The Institute of Chemical Defense (ICD) has also developed several
distance learning products based on these courses that are available through
its Web site, distributed free each year at several military medical
conferences and shipped to military medical commands and treatment
facilities. It distributed about 13,300 educational products last year,
including handbooks, textbooks, CD- ROMs, and videos.

Navy officials told us that they have waiting lists for both the medical
management and field management courses and that there are not enough seats
to meet their requirements. Stating that they had had trouble making enough
seats available in Army courses, they indicated that they had developed
their own, simpler courses. Institute of Chemical Defense officials
administer enrollment for both institutes and strongly disagreed, saying
that the Navy and Air Force routinely ask for fewer slots than the
institutes offer. 26 In fiscal year 1999, the Navy began offering a 1- day
course for general NBC awareness entitled Navy Familiarization Course in the

26 In its comments on the draft, DOD reported that since our visit to
USAMRICD Navy participation had increased and that every Navy slot for the
course had been filled.

Page 24 GAO- 02- 38 Chemical and Biological Medical Readiness

Medical Management of Chemical, Biological, Radiological, and Environmental
Casualties. This training focuses on all medical support personnel, first
responders, and support personnel. The Navy has also started its own 3- day
Chemical, Biological, Radiological, and Environment Casualty Care Management
course. Personnel from the Naval Environmental Health Center and Naval
Environmental Preventive Medicine units conduct this training at the
requesting command. Through fiscal year 2000, 2,337 personnel have had the
1- day awareness course, 463 the 3- day casualty care course.

Considering all these forms of special CB warfare medical training,
approximately 37,000 military medical personnel have been trained in the
past 4 years. (See table 1.)

Although several courses are now available for interested personnel, this
alone does not ensure DOD?s medical readiness. There is no mechanism- either
joint or within a service- for defining the medical NBC training
requirements to support medical readiness. As a result, CB warfare medical
courses are generally voluntary, filled mostly by rank- and- file interest
rather than by command requirements. Most Army personnel who take the
medical management course take the off- site version, which offers only a
half- day of medical training for treatment of biological warfare
casualties. The Army is considering requiring all active- duty physicians
slated to join military units in time of war through the Professional
Officer Filler System to take either form of the medical management course.
Only medical officers at NBC weapons depots are now required to take it, and
only members of civil support teams are required to take field management
training. The Air Force had required everyone to take a minimum
familiarization course but has cut the requirement back to mobile personnel
and allows it to be met by the satellite courses. The Navy requirements are
that personnel deploying to field hospitals learn decontamination
procedures. Little else in the way of NBC medical training is required of
all other physicians, physician assistants, nurses, medics, or corpsmen.

Target populations for the courses generally have not been well identified.
This is important because, without knowing who falls into the target
population, the services cannot size the classes appropriately to address
the population?s need. In contrast, many other Army Medical Department
courses are targeted to a defined population with an estimated attrition
rate. This determines the numbers of slots needed each year to train and
sustain the target group. Courses Are Voluntary,

Target Populations Are Not Fully Identified, Funding Is Unstable, and
Relatively Few Military Health Care Providers Are Trained

Page 25 GAO- 02- 38 Chemical and Biological Medical Readiness

Funding for components of this training has been unstable. Army training
officials told us that funding for CB warfare medical training actually
decreased after the Gulf War and then increased following the passage of the
Combating Proliferation of Weapons of Mass Destruction Act of 1996 (commonly
known as the Nunn- Lugar- Domenici Act) and a report we issued in 1996. 27
Army officials indicated that, although the medical management course had
more stable funding as part of the budget for the Army Medical Department
Center and School, funding for the remaining Institute of Chemical Defense
courses had been reduced. This included the field management course and all
the distance learning programs, which they stated was cut by more than half
for fiscal year 2001 and had been eliminated for fiscal year 2002. 28

When specialized medical training is defined at its broadest, all the
attendees of all the medical courses in the past 4 years, including
satellite distance learning broadcasts and familiarization classes, totaled
37,796. Even without adjusting for the attrition of trained personnel or
trainees taking more than one course, fewer than 18.6 percent of the 203,378
officer and enlisted health care providers in fiscal year 1999 had completed
any specialized CB warfare medical training.

Considering just medical corps officers trained through both the on- site
MCBC course and its less rigorous off- site version means that 5,486 or 9.8
percent of current service end strength have been trained (see table 2). The
Army leads with 16 percent trained. The Navy had 3.3 percent, while the Air
Force trained 6 percent over 4 years.

However, only a small fraction of military medical officers have been fully
trained in the military?s ?gold standard? resident Medical Management of
Chemical and Biological Casualties (MCBC). During the past 4 years, 611
service medical corps physicians have taken the resident course or, more
broadly, 1,375 medical corps personnel (physicians, physician assistants,
and nurses). 29 With the current end strength of 55,978 active and reserve

27 Pub. L. No. 104- 295, title VII, The Intelligence Authorization Act for
Fiscal Year 1997;

Chemical and Biological Defense: Emphasis Remains Insufficient to Resolve
Continuing Problems (GAO/ NSIAD- 96- 103, Mar. 29, 1996).

28 Officials told us that funding for these classes was actually unspent
funds for new CB warfare equipment under development. They stated that since
this equipment had now been fully developed, the money had to be redirected
to produce and field it.

29 Only 4 years of comparable data were available for the various courses.

Page 26 GAO- 02- 38 Chemical and Biological Medical Readiness

duty medical corps officers (not correcting for attrition, which would lower
the estimate), fewer than 2.5 percent have received this training (see table
2). The Army has not trained more than 3.7 percent of its physicians,
physician assistants, and nurses in the MCBC course, while the Navy has
trained 2.4 percent, and the Air Force less than 1 percent.

Table 2: Fiscal Years 1997- 2000 4- Year Medical Personnel CB Warfare
Training Totals as a Percentage of Fiscal Year 2000 End Strength

Training and end strength Army Navy Air Force All

services Totals

CB warfare training 13,385 6, 694 14,051 37,796 Officer medical corps end
strength (physicians, physician assistants, and nurses) 24,761 13,961 17,256
55,978 End strength enlisted medical personnel 81,588 33,768 32,044 147,400
Medical Health Service health care providers 106,349 47,729 49,300 203,378

Percentages

Medical Health Service health care providers receiving any training 12.6%
14.0% 28.5% 18.6% Medical Corps officers receiving MCBC training either on
or off site 16 3.3 6 9.8 Medical Corps officers receiving MCBC on- site
training 3.7 2. 4 0.7 2. 5

Tracking completed training would be necessary to quickly determine who has
received specific individual training or to quickly assemble teams of fully
trained personnel. Neither DOD nor any service has an operating, centralized
system to quickly identify who has received training. The systems that exist
do not consistently track all relevant CB warfare courses. As a result, an
accurate summary of current personnel who have received any particular CB
medical training cannot be given and DOD cannot readily retrieve the
identity of qualified and trained personnel.

The Army Training Requirement and Resources System tracks only the
completion of training for courses on its requirements lists. Although the
medical management course is tracked for Army personnel, the field
management course, the combat casualty course, and other mass casualty
courses such as Medical Effects of Ionizing Radiation and Radiological
Hazards Training are not. Army manpower requirement planners do not track
training either; they track only the basic area of concentration for
officers who are medical specialists. Training compliance checks still have
to be done through the unit or hospital commander. Officials told us that a
Tracking Is Too Weak to

Support Meaningful Training Requirements

Page 27 GAO- 02- 38 Chemical and Biological Medical Readiness

centralized training and competency database like the one maintained by the
Joint Commission on Accreditation of Health Care Organizations for civilian
medical care is not available and cannot be implemented. However, that they
track only medical specialists? area of concentration, not their military
training, is inconsistent with medical planners? statements that it is
training, not specialization, that ensures CB warfare readiness.

The Navy stated that it had no way of tracking training throughout a career
but that Navy medicine needed a system to track it. Individual commanders
are supposed to track their unit?s training and combat readiness, but
officials told us that this is typically only a count of how many personnel
have had the required training and what percentage have their shots or know
how to wear protective gear. The commands are supposed to use the Standard
Personnel Management System to report their information so that Navy
Medicine can verify compliance with training requirements. However, the
system has not been working for some time, and they were without aggregate
data.

Similarly, the Air Force does not maintain a list of trained personnel. Most
of the task of ensuring Air Force wartime medical readiness falls on the
commanders of the Military Treatment Facilities, who are expected to report
on unit readiness to their major commands through the Medical Readiness
Decision Support System. It tracks officers? current assignment, primary
training, and additional certifications. However, most Air Force training
consists of the Army satellite courses, which are not considered part of
Continuing Medical Readiness Training (CMRT) and are not recorded by the
CMRT system. The Air Force does not mandate or track completion of MCBC
training.

Proficiency testing is needed to ensure that personnel who have completed
training are actually able to perform key tasks. While the Army?s courses
conduct hands- on testing, trainees are not required to pass a final test to
receive credit for course completion or for Continuing Medical Education.
Although each service establishes proficiency and currency standards for NBC
defense training, most standards consist of the local commander?s check on
his or her unit?s readiness, not individual proficiency. For example, Navy
commanders are supposed to check their units? readiness, but we were told
that they have no proficiency measures. Moreover, Army officials stated that
units do medical proficiency training but would be very unlikely to train
for NBC. They also said that no one regulates medical operations to make
sure they follow the standard Proficiency Is Not

Systematically Tested

Page 28 GAO- 02- 38 Chemical and Biological Medical Readiness

doctrine and that lessons- learned observers need not be certified. Mastery
of subject matter and treatment receives insufficient systematic
verification in either the classroom or the field. Similarly, the elaborate
credentialing practices of peacetime medical care have no parallel in
wartime. While this yields substantial flexibility, it may also raise
questions about quality.

One general indication that unit NBC training is inadequate comes from
results at the Army Combat Training Centers. According to the March 2000
Annual Chemical and Biological Defense Program report, Army units at the
company, battalion, and brigade levels were unable to perform all NBC tasks
?to standard.? The 2000 report also concludes that this ?less than
satisfactory performance at the Combat Training Centers is directly
attributable to lack of homestation NBC training (p. 136).?

Another measure is an evaluation (Medical Training 2000) conducted by the
Army that included a criterion- referenced assessment of the proficiency of
its medical first responders- medics. According to the Army, this is
important because the skills that may be key to addressing a CB attack,
including rapid assessment of unusual symptoms, are not typically practiced
in garrison. The Army study of its active duty medics found that only 16
percent passed a multiple choice test on assessing and managing NBC
casualties, and the Army concluded that this indicated a very low degree of
general medical readiness among medics. (See figure 1.) Their readiness to
treat NBC casualties was lowest of all skills measured. (Navy and Air Force
officials told us that they had no comparable assessments of proficiency
among medical personnel.)

Page 29 GAO- 02- 38 Chemical and Biological Medical Readiness

Figure 1: Proficiency Measures From the Army Study Medical Training 2000,
Slide from Medic Training 2000 Briefing Presented by Major General James B.
Peake

Source: Medic Training 2000 briefing presented by Major General James B.
Peake, Commanding General, AMEDD Center and School, at the Medic- WMD 2000
Conference, April 3- 6, 2000. See also U. S. Army Center for Healthcare
Education and Studies, Medical Training 2000 (San Antonio, Texas: Fort Sam
Houston, Army Medical Department Center and School, n. d.).

The technical report of the Medical Training 2000 Study completed by the U.
S. Army Center for Healthcare Education and Studies concluded:

MEDIC TRAINING 2000 Outcomes at Baseline

Skill Medics* perceiving they can perform the skill

Medics* passing a cognitive test (>=70%)

Medics* passing a hands-on skill test (>=70%)

Medics* passing a hands-on skill test

(critical criteria standard)

Assess Casualty 69% 50% 17% 3% Manage Airway

84% 66% 51% 2% Control Bleeding

91% 54% 20% 8% Insert IV 93% 89% 77% 29% Treat NBC Casualty

25% 16% not tested not tested

*Total military medical experience of medics tested in Phase I (N = 347)

LOW

Page 30 GAO- 02- 38 Chemical and Biological Medical Readiness

?Finally, special attention must be drawn to the problem of training combat
medics to treat NBC casualties. Data from self- ratings of proficiency,
supervisors? ratings of proficiency, and written tests (Phases I, II, and
III) indicated that 4 out of 5 combat medics had significant deficits in
this area. In every evaluation conducted in this study, the lowest scores
were always for treating NBC casualties. Both academic and unit training
failed to teach combat medics this essential skill. It is unlikely that
there will be a simple solution to this problem. Assessing and treating an
NBC casualty is not a fundamental skill. Combat medics must have a good
grasp of the principles required to treat a conventional casualty before
they can begin to grasp the complexities involved in caring for NBC
casualties. Moreover, high fidelity NBC training is complex and resource-
intensive. The ability to treat an NBC casualty was not tested with a hands-
on test in this study because the logistical burden was too high. If the
ability to treat an NBC casualty is critical to the role of a 91B10level
combat medic, then new academic and unit training programs as well as
adequate logistical support must be developed to teach and sustain the
skill.? 30

Given that medics had received only 8 hours of CB familiarization with their
basic training and that even the summaries available from Army field manuals
(as excerpted in appendix I) are necessarily rather technical, these results
are not surprising. These low proficiency scores come just as the Army is
preparing for more mobile combat where medics may be deployed farther from
higher- level support.

In May 1998, the Chairman of the Joint Staff published guidance for exercise
and training objectives that identified NBC defense and force protection as
the top training issues. Nevertheless, in March 2000, DOD?s Chemical and
Biological Defense Program Annual Report concluded that CB scenarios are not
adequately exercised. The report found that although the Army had more than
750 models and simulations, very few combat simulations incorporated the
effects of NBC and none incorporated all aspects. 31

Officials told us that although medical response to a CBW incident has been
exercised domestically, outside the United States comparable

30 U. S. Army Center for Healthcare Education and Studies, Medical Training
2000 (San Antonio, Texas: Fort Sam Houston, Army Medical Department Center
and School, n. d.), p. 6.

31 DOD, Chemical and Biological Defense Program Annual Report to Congress

(Washington, D. C.: March 2000), p. 133. Also see Chemical and Biological
Defense: Units Better Equipped, but Training and Readiness Reporting
Problems Remain

(GAO/ NSIAD- 01- 27, Nov. 14, 2000). A Minority of Medical

Units Participate in Service CB Exercises and the CINCs Very Rarely Exercise
CB Medical Readiness

Page 31 GAO- 02- 38 Chemical and Biological Medical Readiness

exercises of medical support have been minimal. Although the service
surgeons general have recently begun integrating chemical and a few
biological scenarios into their medical exercises, medical planners from
each of the five unified commands reported that these commands have not
conducted a realistic field exercise of medical support for chemical or
biological warfare. A key readiness review, which is used to advise the
president on readiness to implement the national security strategy, has
never set the unified commanders a scenario requiring medical support for
weapons of mass destruction.

Army medical officials stated that the Army generally does not exercise
casualty management, evacuation, triage, or decontamination for CBW
scenarios. The Army conducts training exercises for its field hospitals,
battalion aid stations, and medical companies at its three combat training
centers. Officials told us that in recent years they have generally included
a chemical scenario and that they piloted a biological scenario in 1999.
Although Army Health Care Operations officials told us these exercises were
more realistic than those that might be performed at their home base, they
exclude the more persistent chemical agents that could bring the exercise to
a halt. In general, most brigades go through the combat training centers
about every 2 years, with two or three companies of 130 troops from each
brigade, or 10 percent of the troops being directly involved in the chemical
play. Simulated casualties range from 10 to about 150 of 260 personnel.
Demonstrating the importance of field exercises, Army officials told us
that, in the first training exercise, casualty rates can run as high as 75
percent, but as the units learn how to respond this drops sharply to as low
as 10 percent. However, according to Army health care operations officials,
it is not unusual to have 100 percent turnover in personnel every 2 years.

The Army also has command post staff exercises that are limited to decision
making and do not involve units in the field. The AMEDDX exercise, for
example, involves units that volunteer to train in evacuation, reception,
and treatment, including CB casualties. Golden Medic is a command post
exercise for Army reserve units that includes some CB play but does not
exercise medical treatment. Even though personnel not directly involved in
CB play can learn from after- action reports, the modest proportion of Army
units annually participating in exercises involving CB medical support
(combined with the turnover rate among medical personnel) raise questions
about medical readiness for CB in the Army, DOD?s lead agent for CB medical
readiness. The Services Train a Small

Minority of Units With Field Exercises of CB Medical Support

Page 32 GAO- 02- 38 Chemical and Biological Medical Readiness

Like all hospitals certified by the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO), Air Force hospitals are required to
exercise their ability to respond to mass casualties annually. In addition,
depending on local threat conditions, they are required to conduct exercises
in responding to an attack. It was not clear to Air Force headquarters how
many of these involve CB, as the hospitals are not required to report the
content or result to the major commands. Air Force health care officials
said that in the past they have had difficulty getting medical care included
in regular combat readiness exercises and even then the medical play was
often cancelled. However, they reported having made significant strides
since May 2000 with a considerable shift in their organizational staffing.
Army and Air Force officials told us that the completion of the JRCAB
protocols for the treatment of CB casualties has allowed more meaningful
exercise of CB medical care. The protocols were loaded onto handheld
computers as patient care algorithms that allow exercise umpires to score
how the simulated casualties fared. As a result, the Air Force was able to
include medical management of chemical or biological casualties in three of
its recent major field exercises- Pacific Warrior, Consequence Island, and
Golden Medic. Air Force officials estimated that roughly 15 to 20 percent of
medical staff have participated in exercises of medical care of chemical or
biological casualties.

Navy officials told us they had not conducted a field exercise of CB medical
support. They stated that a full response to CB would quickly bankrupt the
services. They argued that any full response plan would have to be joint.
The Navy reported that in general only a small percentage of their exercises
involve medical care. Officials told us that medical play during routine
combat readiness exercises often lacks a scenario involving a CB event
because it becomes ?too hard,? or the CB portion that was planned is
eliminated because ?it does not let the warfighter exercise his needs.? They
have recently begun to include chemical or biological care tabletop
exercises for medical staff. Their most recent Vanguard exercise included a
response to both chemical and biological agents (sarin and plague). Another
is planned with a biological agent for October 2001. Their recent science
and technology exercise included a response to a chemical agent (sarin).
Another tabletop exercise was played against chemical and biological agents
(smallpox). Two smaller tabletop strategic exercises for the leaders of Navy
medicine were held at Camp Lejeune and included a response to plague.

Although the service surgeons general have begun integrating chemical and a
few biological scenarios into their medical exercises, validating any of the
services? planning assumptions would require both realistic CB Joint CB
Medical Readiness Is

Rarely Tested

Page 33 GAO- 02- 38 Chemical and Biological Medical Readiness

scenarios and full medical participation in joint combat readiness
exercises. For example, Army officials voiced concern about the lack of
joint exercises to support key Air Force lift capacity assumptions. The
joint staff requires the unified commands to examine quarterly scenarios of
regional warfare. The focus of the review is determining the armed forces?
current readiness to execute the full range of the national military
strategy, including peacetime engagement, deterrence, conflict prevention,
and winning the nation?s wars. Service and Joint Staff told us that as of
June 2000 this key review had never asked the CINCs to address a scenario
that incorporated medical support for CB contingencies. We were told it
might do so in the future.

Given the difficulty and expense of exercising realistic CB scenarios, some
service officials argued that more has to be done at the joint level. For
example, Army officials voiced concerns about the lack of joint exercises to
support Air Force lift capacity assumptions. The Joint Exercise Management
Program of the joint staff (J- 7) maintains data on all exercises planned by
the various CINCs and major commands in order to coordinate approval and
funding of the exercises. These data provide a rough approximation of
pertinent CINC exercises based on keyword searches of exercise abstracts.
Overall, CINCs planned 2,714 exercises between fiscal years 1993 and 2005
(figure 2). Of these, 278 (or about 10 percent) involved some medical play,
and 38 (1 percent) involved chemical or biological warfare scenarios. Only 4
exercises involved both medical support and either chemical or biological
scenarios.

Page 34 GAO- 02- 38 Chemical and Biological Medical Readiness

Figure 2: Numbers of Planned CINC Exercises, Fiscal Years 1993- 2005

Source: J- 7, Joint Exercise Management Program, April 2001.

Although the frequency of all planned CINC exercises rose after the Gulf War
and then gradually declined to 201 in 2000, the number of joint medical
exercises of all types peaked at 31 in 1995 and fell to 16 in 2000. (See
figure 2.) Exercises incorporating chemical or biological warfare (CB), and
in particular medical response to chemical or biological warfare (CB
Medical) have remained few and far between. Given that the threat was said
to be increasing, these trends are at odds. Indeed, the last joint CB
medical exercise that would have been completed was in 1994, and the next
one is not planned until 2005. Figure 2 shows the total number of

29 25 31 18 26 27 20 16 19 15 18 17 17 3 9 1 0 00 3 2 4 44 44 0 2 0 00 00 00
00 02

0 50

100 150

200 250

300 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Medical CB CB Medical Total

Page 35 GAO- 02- 38 Chemical and Biological Medical Readiness

planned joint exercises for 1993-- 2005, as well as those involving medical
support and CBW. 32

Overall, little exercising has been done above the level of unit commanders.
The CINCs do not track these unit exercises, and neither they nor DOD could
provide us with a summary of them. Essentially, although there are more than
150 joint exercises planned annually, relatively few include either CB
warfare or medical matters, and virtually no joint exercises include both CB
warfare and field medical response. Medical officials told us that in combat
exercises the only roles generally played by medical staff are to assist in
recognizing a CB event and planning the logistics required for handling it.
Medical staff commented that both CB warfare and medical support have to
fight for inclusion in combat readiness exercises. The problem they saw was
that CB defense is not the primary objective of any exercise. Medical
planners argued that, on the one hand, if CB defense were made the primary
exercise objective without direction from the Joint Chiefs, then it would be
harder to get broad participation in the exercise. On the other hand, when
CB defense is not the primary objective, then the threat tends to be watered
down so that other objectives will not be disrupted by showstoppers.

The term ?mass casualties? refers to any level of casualties that overwhelms
the existing medical resources at a given site or level of care. Army
planners charged with the medical response to CBW told us that a realistic
mass casualty CB scenario had never been exercised. They stated that ?their
realistic working assumption was that a genuine CB event in the battlefield
would overwhelm the medical system.? They said that given

32 U. S. Pacific Command officials also confirmed that PACOM had conducted
command post CB exercises, but had not included a field exercise of medical
support. U. S. Central Command staff could not recall any field exercises of
CB medical support. CENTCOM?s Desert Breeze exercises had a tabletop CB
warfare medical component. The Neon Falcon exercises included CB warfare
decontamination but not medical treatment. Central Command officials also
said that while field exercises are generally the responsibility of the
component commands, they did not have any knowledge of these exercises or
their lessons learned. They reported that the Joint Unified Lessons Learned
System for reporting and retrieving lessons learned from exercises had been
down for a year and a half. Joint Forces Command reported two exercises. In
November and December 1999, it trained and exercised to plan for the
millennium celebration. No medical units were actually deployed. In May
2000, it participated in the Top Officials (TOPOFF) exercise, whose purpose
was to prepare to conduct surveillance, decontamination, treatment, and
evacuation of chemical victims in Portsmouth, New Hampshire, and biological
victims in Denver, Colorado. DOD had no significant field role. No DOD
medical units were deployed in a field role other than a Chemical Biological
Incident Response Force to assist with decontamination. U. S. European
Command also reported that it had not conducted CB exercises.

Page 36 GAO- 02- 38 Chemical and Biological Medical Readiness

that the medical system will be overwhelmed, mass casualty scenarios should
be exercised to prepare our medical force leaders to sustain medical
operations in the face of such an event. DOD health affairs officials
acknowledged that they did not know how many casualties they could handle
and agreed that they could have better knowledge of their current
capabilities.

In sum, DOD development of appropriate CB courses is an important
contribution to adequate readiness but may not be sufficient to guarantee
readiness. Treating CB casualties is an advanced medical skill, but without
requirements, relatively few military medical personnel receive advanced
training. Army testing of medics confirmed that proficiency was low. Army
officials characterized the funding for individual CB medical training as
unstable. Unit training appears insufficient because skills to ensure
readiness are rarely exercised due to conflicting priorities encountered by
both warfighters and medical staff and because it is difficult and
expensive. Even individuals who have been trained cannot be readily
identified because either the tracking systems do not exist or they are not
currently functioning. Certification based on proficiency standards in the
classroom or the field is not being done, in part because neither the
metrics nor the standards have been developed.

The President, Secretary of Defense, and Joint Chiefs have all emphasized
the importance of preparing U. S. military forces for emerging CB threats.
Last spring, DOD reported to the Congress that ?the probability of U. S.
forces encountering CB agents during worldwide conflict remains high.? 33
However, we found that the likelihood of CB casualties receiving proficient
medical care remains low. Although we found efforts to plan and train for
these threats, there is a wide and longstanding gap between DOD?s appraisal
of CB threats and DOD?s medical preparedness to meet them. This suggests a
lack of consensus about the threat, a failure of highlevel leadership, or
the acceptance of a potentially high level of risk.

DOD and the services have not adequately modeled or evaluated medical
specialty mix or fully resolved their differences. DOD has not developed
comprehensive, meaningful training requirements, adequate tracking systems,
or rigorous proficiency testing. The available evidence indicates

33 DOD, Chemical and Biological Defense Program Annual Report to Congress

(Washington, D. C.: March 2000), p. i. Conclusions and

Recommendations

Page 37 GAO- 02- 38 Chemical and Biological Medical Readiness

that proficiency is low. From training only a fraction of personnel to
failing to conduct realistic, challenging combat field exercises that
include CB medical treatment, DOD has not fully responded to the threat as
stated. Consequently, 10 years following Operation Desert Storm, serious
concerns remain about DOD?s capacity to provide medical support for CB
warfare casualties.

We recommend that the Secretary of Defense 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, directing the Joint Staff to integrate biological medical
readiness in Defense Planning Guidance.

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, we recommend that the Secretary of Defense
direct that

1. 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.

2. 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 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.

3. The services develop CB medical training requirements and assess the
effectiveness of the training with rigorous proficiency metrics and
standards.

4. DOD develop and maintain information management systems to monitor
completion of required CB training and track the proficiency

Page 38 GAO- 02- 38 Chemical and Biological Medical Readiness

of medical personnel, at least for medical first responders and personnel in
high- risk areas of operation.

5. 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.

DOD provided written comments on a draft of this report on September 10,
2001. These comments are reproduced in appendix IV. In view of the September
11 attack, we reconfirmed with DOD that the report was still unclassified
and cleared as amended. DOD concurred with all our recommendations and
provided additional technical comments which we have incorporated as
appropriate. DOD indicated that it plans to take a number of specific steps
but did not make clear that they will collectively redress the lack of
clarity regarding expectations for CB medical readiness.

In responding to our recommendation that the Secretary of Defense address
the gap between the threat as stated and the current level of medical
readiness, DOD stated that the Joint Staff will be asked to reexamine CB
training issues and to propose adjustments to enhance medical readiness. It
is not clear, however, that referring the matter to the Joint Staff for
further study will be sufficient to address the gap, clarify expectations,
or integrate medical readiness for biological warfare in Defense Planning
Guidance.

To the extent that DOD views CB warfare as a serious threat and expects the
nation?s military medical forces to prepare for its contingencies, we
offered several additional recommendations. In response to our
recommendation that DOD complete the Common User Database and validate it
with proficiency testing, DOD stated that the Joint Staff will be requested
to coordinate the completion of the Common User Database and to consider
service- specific environments. However, it remains unclear whether DOD
intends to identify specific types of personnel qualified to treat specific
problems and to validate their qualifications with proficiency testing.

DOD had several comments regarding our recommendation that it use enhanced
modeling capabilities to develop risk assessments for various evacuation
rates. Regarding modeling capabilities, it stated that the MAT Agency
Comments

and Our Evaluation

Page 39 GAO- 02- 38 Chemical and Biological Medical Readiness

can now provide requirements once casualty rates have been determined. We
note that this process still cannot generate defensible specialty mix
requirements until the Common User Database identifies the specific types of
personnel qualified to address specific patient conditions. DOD also stated
that the many variables and the absence of historical casualty data have so
far precluded arriving at any one set of conclusions that would be more
logically defensible than any other set. We do not wish to minimize the
difficulties associated with modeling and estimating medical requirements
for CB attacks, and for this reason have suggested modeling a range of
assumptions to assess risks.

Regarding evacuation capabilities, DOD specifically concurred with the need
to better assess the percentage of casualties needing evacuation but not the
actual calculation of medical requirements based on delay estimations and
evacuation capacity. However, we were told that evacuation rates have a
tremendous impact on the size of the medical forces required on the ground
and in the air. We found that Army and Air Force officials strongly
disagreed about actual evacuation capabilities. Army officials told us that
because of this dispute, the Army is out of compliance with this part of the
Joint Strategic Capabilities Plan. Therefore, without interservice agreement
on evacuation, there is effectively no coherent process for estimating
overall joint medical requirements. DOD further acknowledged that the
evacuation issue is greatly complicated by the BW threat. This underscores
the need to use enhanced modeling capabilities to assess risks.

DOD responded to our recommendation to develop CB medical training
requirements by saying that it had formed a working group for NBC medical
training requirements and that the Joint Staff will be asked to establish an
NBC oversight group. However, DOD was silent about assessing the
effectiveness of these requirements with rigorous proficiency metrics and
standards.

DOD concurred with our recommendation to improve information management
systems, and it suggested that we broaden this to recommend a joint system
to track the monitoring of training and the proficiency of all personnel
identified for functioning in a CB environment. We concur and have changed
the recommendation. While having servicetracking systems would be an
improvement, a joint system would be best. Similarly, although the scope of
this report was limited to CB readiness, we agree that it would be logical
and appropriate to include medical readiness for nuclear events in such as
system.

Page 40 GAO- 02- 38 Chemical and Biological Medical Readiness

DOD concurred with our recommendation to increase the realistic exercise of
medical support. It stated that the Assistant Secretary of Defense for
Health Affairs will request heightened medical participation in all relevant
exercises. However, we note that the Assistant Secretary?s concurrence is a
necessary but insufficient condition for fully implementing this
recommendation. Most exercises are controlled not by the medical staff but
by those responsible for warfighting operations. Concurrence of the military
operations staff will be essential if medical participation is to be
included in combat exercises and not the first thing cut when it gets in the
way of other goals or becomes ?too hard.? DOD was also silent about the
realistic exercise of mass casualties- exercises that explore the limits of
medical capabilities and the full consequences of scenarios that overwhelm
them.

As we agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from its issue date. We will then send copies of this report to the
Secretary of Defense, the Ranking Minority Member of your Subcommittee, and
other interested congressional committees and members. We will also provide
copies to others on request. If you have any questions or would like
additional information, please call me at (202) 512- 2700. Other key
contacts and contributors are listed in appendix V.

Sincerely yours, Nancy R. Kingsbury, Managing Director Applied Research and
Methods

Appendix I: Specific Signs, Symptoms, Diagnoses, and Treatment for Some
Common Chemical and Biological Agents

Page 41 GAO- 02- 38 Chemical and Biological Medical Readiness

Agent Signs, symptoms, and diagnosis Treatment

Pulmonary: Phosgene Eye and airway irritation, shortness of breath, chest
tightness, and delayed pulmonary edema Termination of exposure,
resuscitation, enforced bed

rest and observation, oxygen with or without positive airway pressure for
signs of respiratory distress, and other supportive therapy as needed Nerve:
GA, GB, GD, GF, VX Vapor:

Small exposure- miosis, rhinorrhea, mild difficulty breathing

Large exposure- sudden loss of consciousness, convulsions, apnea, flaccid
paralysis, copious secretions, miosis

Liquid on skin: Small to moderate exposure- localized sweating, nausea,
vomiting, feeling of weakness

Large exposure- sudden loss of consciousness, convulsions, apnea, flaccid
paralysis, copious secretions

Administration of MARK I Kits (atropine and pralidoxime chloride); diazepam
in addition if casualty is severe; ventilation and suction of airways for
respiratory distress Management of a casualty with nerve agent intoxication
consists of decontamination, ventilation, administration of the antidotes,
and supportive therapy. The condition of the patient dictates the need for
each of these and their order.

Vesicants: Mustard, Lewisite Asymptomatic latent period (hours): Erythema
and blisters on the skin; irritation, conjunctivitis, corneal opacity, and
damage in the eyes; mild upper respiratory signs to marked airway damage;
gastrointestinal (GI) effects; bone marrow stem cell suppression

Decontamination immediately after exposure is the only way to prevent
damage. There is no specific supportive therapy. The eyes are the organs
most sensitive to mustard vapor injury. The management of a patient exposed
to mustard may be simple, as in providing symptomatic care for a sunburn-
like erythema, or extremely complex, as in providing total management for a
severely ill patient with burns, immunosuppression, and multisystem
involvement. Anthrax Inhalation: Incubation period of 1- 6 days:

Fever, malaise, fatigue, cough, and mild chest discomfort followed by severe
respiratory distress with dyspnea, diaphoresis, stridor, and cyanosis

Within 24- 36 hours after onset of severe symptoms: Shock and death

Physical findings are nonspecific. Although effectiveness may be limited
after symptoms

are present, high- dose antibiotic treatment with penicillin, ciprofloxacin,
or doxycycline should be undertaken. Supportive therapy may be necessary.

Plague Pneumonic plague (incubates 2- 3 days): High fever, chills, headache,
hemoptysis, and toxemia, progressing rapidly to dyspnea, stridor, and
cyanosis; death from respiratory failure, circulatory collapse, and a
bleeding diathesis Bubonic plague (incubates 2- 10 days): Malaise, high
fever, and tender lymph nodes; may progress spontaneously to the septicemic
form, with spread to the central nervous system and lungs

Early administration of antibiotics is very effective. Supportive therapy is
required.

Appendix I: Specific Signs, Symptoms, Diagnoses, and Treatment for Some
Common Chemical and Biological Agents

Appendix I: Specific Signs, Symptoms, Diagnoses, and Treatment for Some
Common Chemical and Biological Agents

Page 42 GAO- 02- 38 Chemical and Biological Medical Readiness

Agent Signs, symptoms, and diagnosis Treatment

Viral hemorrhagic fevers VHFs are febrile illnesses that can be complicated
by easy bleeding, petechiae, hypotension, and even shock, flushing of the
face and chest, and edema. Constitutional symptoms such as malaise,
myalgias, headache, vomiting, and diarrhea may occur.

Intensive supportive care may be required. Antiviral therapy with ribavirin
may be useful in several of these infections. Convalescent plasma may be
effective in Argentine hemorrhagic fever.

Botulinum toxins Ptosis, generalized weakness, dizziness, dry mouth and
throat, blurred vision and diplopia, dysarthria, dysphonia, and dysphagia
followed by symmetrical descending flaccid paralysis and respiratory
failure. Symptoms begin as early as 24- 36 hours but may take several days
after inhalation of toxin. The botulinum toxins as a group are among the
most toxic compounds known to humans. No routine laboratory findings.
Biowarfare attack should be suspected if multiple casualties simultaneously
present with progressive descending bulbar, muscular, and respiratory
weakness.

Intubation and ventilatory assistance for respiratory failure. Tracheostomy
may be required. Administration of heptavalent botulinum antitoxin (IND
product) may prevent or decrease progression to respiratory failure and may
hasten recovery.

Source: Field Management of Chemical Casualties Handbook, 2nd ed. (Aberdeen
Proving Ground, Md.: USAMRICD, July 2000), and Medical Management of
Biological Casualties Handbook, 2nd ed. (Fort Detrick, Md.: USAMRIID, August
1996).

Appendix II: General Distinguishing Features of Chemical and Biological
Terrorism

Page 43 GAO- 02- 38 Chemical and Biological Medical Readiness

Feature Chemical Biological

Time from attack to illness Rapid: minutes to hours Delayed: days to weeks
Distribution of victims Downwind from point of release Widely spread through
the battlefield and

beyond First personnel to respond Soldiers, medics, corpsmen Sick call
physicians and nurses, infectious

disease physicians, epidemiologists, public health officials, laboratory
personnel Release site Swiftly discovered; area of attack can be

cordoned off Difficult to identify; area of attack cannot be cordoned off

Decontamination of patients and environment Acutely important in most cases
Not needed in most cases Medical treatment Antidotes Vaccines, antibiotics
Patient isolation Not needed after decontamination Crucial if communicable
disease is involved;

advance hospital planning for isolating many patients is critical

Source: D. A. Henderson, ?The Looming Threat of Bioterrorism,? Science, 283:
5406 (Feb. 26, 1999); and DOD

Appendix II: General Distinguishing Features of Chemical and Biological
Terrorism

Appendix III: U. S. Military CB Warfare Medical Training Summary Tables,
Fiscal Years 1997- 2000

Page 44 GAO- 02- 38 Chemical and Biological Medical Readiness

Table 3: Officers and Enlisted Personnel Trained in MCBC Courses, Fiscal
Years 1997- 2000

Course Days in course Army Navy Air Force All

services

Total in- house 7 929 330 116 1,375 Medical Corps Officers: physicians,
physician assistants, nurses

872 290 96 1,258 Enlisted: medics, corpsmen 57 40 20 117 Total off- site 3
4, 201 394 1,288 5,883 Medical Corps Officers: physicians, physician
assistants, nurses

3,108 173 947 4,228 Enlisted: medics, corpsmen 1,093 221 341 1,655 Total
trained 5,130 724 1,404 7,258

Annual average 1, 283 181 351 1,815 Table 4: Officers and Enlisted Personnel
Trained in FCBC Since Fiscal Year 1999 Course Days in

course Army Navy Air Force All services

In- house 5 724 71 13 808 Off- site 3 668 1 17 686

Total 1,392 72 30 1,494 Table 5: USAMRIID Biological Warfare Satellite
Broadcasts, Fiscal Years 1997- 2000 Year Army Navy and

Marines Air Force All services

1997 942 856 1,558 3,356 1998 2,422 992 7,978 11,392 1999 1,869 939 2,431
5,239 2000 1,630 390 650 2,670

Total 6,863 3,177 12,617 22,657

Appendix III: U. S. Military CB Warfare Medical Training Summary Tables,
Fiscal Years 1997- 2000

Appendix III: U. S. Military CB Warfare Medical Training Summary Tables,
Fiscal Years 1997- 2000

Page 45 GAO- 02- 38 Chemical and Biological Medical Readiness

Table 6: Military Health Service Total End Strength, Fiscal Year 1999 Duty
status Army Navy Air

Force Total Active duty

Physician Medical Corps 4, 332 4,086 3,951 12,369 Nurse Corps 3, 300 3,146
4,333 10,779 Physician assistants 478 235 455 1,168 Total active physicians,
physician assistants, and nurses 8,110 7,467 8,739 24,316

Reserve and Guard

Physician Medical Corps 4, 380 2,707 2,472 9,559 Nurse Corps 11,778 3, 702
5,895 21,375 Physician assistants 493 85 150 728 Total Reserve and Guard
16,651 6, 494 8,517 31,662

Total active, Reserve, and Guard physicians, physician assistants, and
nurses

24,761 13,961 17,256 55,978 Enlisted

Enlisted active duty 29879 22,459 20,711 73,049 Enlisted Reserves 51,709
11,309 11,333 74,351

Total enlisted 81,588 33,768 32,044 147,400 Medical Health Service

Active duty Medical Health Service officers and enlisted 37,989 29,926
29,450 97,365

Total Medical Health Service health care providers 106,349 47,729 49,300
203,378

Appendix IV: Comments From the Department of Defense

Page 46 GAO- 02- 38 Chemical and Biological Medical Readiness

Appendix IV: Comments From the Department of Defense

Appendix IV: Comments From the Department of Defense

Page 47 GAO- 02- 38 Chemical and Biological Medical Readiness

Appendix IV: Comments From the Department of Defense

Page 48 GAO- 02- 38 Chemical and Biological Medical Readiness

Appendix V: GAO Contacts and Staff Acknowledgments

Page 49 GAO- 02- 38 Chemical and Biological Medical Readiness

Betty Ward- Zukerman (202) 512- 2732 Daniel Rodriguez (202) 512- 3827

In addition to the persons named above, Penny Pickett, Jonathan Tumin, and
Teia Harper made key contributions to this report. Appendix V: GAO Contacts
and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

Related GAO Products Page 50 GAO- 02- 38 Chemical and Biological Medical
Readiness

Bioterrorism: Federal Research and Preparedness Activities (GAO- 01915,
September 28, 2001).

Chemical and Biological Defense: Improved Risk Assessment and Inventory
Management Are Needed (GAO- 01- 667, September 28, 2001).

Chemical Weapons: FEMA and Army Must Be Proactive in Preparing States for
Emergencies (GAO- 01- 850, August 13, 2001).

Coalition Warfare: Gulf War Allies Differed in Chemical and Biological
Threats Identified and in Use of Defensive Measures (GAO- 01- 13, April 24,
2001).

Chemical and Biological Defense: Units Better Equipped, but Training and
Readiness Reporting Problems Remain (GAO/ NSIAD- 01- 27, Nov. 14, 2000).

West Nile Virus: Preliminary Information on Lessons Learned

(GAO/ HEHS- 00- 142R, June 23, 2000).

Biological Weapons: Effort to Reduce Former Soviet Threat Offers Benefits,
Poses New Risks (NSIAD- 00- 138, April 28, 2000).

Medical Readiness: DOD Continues to Face Challenges in Implementing Its
Anthrax Vaccine Immunization Program (T- NSIAD- 00- 157, April 13, 2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are Poorly
Managed (GAO/ T- HEHS/ AIMD- 00- 59, Mar. 8, 2000).

Defense Health Care: Tri- Service Strategy Needed to Justify Medical
Resources for Readiness and Peacetime Care (GAO/ HEHS- 00- 10, Nov. 3,
1999).

Combating Terrorism: Observations on the Threat of Chemical and Biological
Terrorism (GAO/ T- NSIAD- 00- 50, Oct. 20, 1999).

Military Readiness: Full Training Benefits From Army?s Combat Training
Centers Are Not Being Realized (GAO/ NSIAD- 99- 210, Sept. 17, 1999).
Related GAO Products

Related GAO Products Page 51 GAO- 02- 38 Chemical and Biological Medical
Readiness

Combating Terrorism: Need for Comprehensive Threat and Risk Assessments of
Chemical and Biological Attacks (GAO/ NSIAD- 99- 163, Sept. 14, 1999).

Combating Terrorism: Analysis of Federal Counterterrorist Exercises

(GAO/ NSIAD- 99- 157BR, June 25, 1999).

Combating Terrorism: Issues to Be Resolved to Improve Counterterrorism
Operations (GAO/ NSIAD- 99- 135, May 13, 1999).

Combating Terrorism: Observations on Biological Terrorism and Public Health
Initiatives (GAO/ T- NSIAD- 99- 112, Mar. 16, 1999).

Defense Infrastructure: Central Training Funding Projected to Remain Stable
During 1997- 2003 (GAO/ NSIAD- 98- 168, June 30, 1998).

Medical Readiness: Efforts Are Underway for DOD Training in Civilian Trauma
Centers (GAO/ NSIAD- 98- 75, Apr. 1, 1998).

Military Readiness: Reports to Congress Provide Few Details on Deficiencies
and Solutions (GAO/ NSIAD- 98- 68, Mar. 30, 1998).

Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed
Results in Bosnia (GAO/ NSIAD- 97- 136, May 13, 1997).

Wartime Medical Care: Personnel Requirements Still Not Resolved

(GAO/ NSIAD- 96- 173, June 1996).

Chemical and Biological Defense: Emphasis Remains Insufficient to Resolve
Continuing Problems (GAO/ NSIAD- 96- 103, Mar. 29, 1996).

(713054)

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