EHJ January 2004, pages 6-9
Military EHOs have a pivotal role in planning health defence, but just how is environmental health integrated and managed on operations? Major James Fletcher describes how environmental health support is delivered throughout the four phases of an operation - force preparation, force deployment, conflict and post conflict

Operation TELIC (OP TELIC) is part of the US-led multi-national coalition to eliminate weapons of mass destruction in Iraq in order to achieve a stable and secure country. It represented the largest deployment of regular and Territorial Army (TA) tri-service environmental health personnel (figure 1) and without doubt, the environmental health sections made an outstanding contribution to the overall success of the mission. For the army environmental health cadre, OP TELIC presented the opportunity to test and validate some of the operational environmental health concepts that have been developed in recent years, particularly, how best to deploy and use the environmental health sections to support units, throughout the operational phases.

In many aspects, the deployment was unique and figure 2 outlines the usual deployment of an armoured division with its three armoured brigades, supported by two environmental health sections, each comprising of one EHO, usually a captain, and seven environmental health technicians. One section will deploy with the close support (CS) medical regiment, providing first line environmental health support to brigade units, and the other with the general support (GS) medical regiment responsible for providing environmental health support to the rear echelons.

The sections are equipped with tentage, vehicles, communications and a range of monitoring equipment from water test kits (biological and chemical) for testing potential water sources for war gases or chemical contaminants, to heat stress monitors. This enables them to operate independently of the medical regiment, but under the direction of the senior EHO at the divisional headquarters.

OP TELIC saw the division deploy with only one of its armoured brigades, and two other very different types of brigade, the 16 Air Assault (AA) brigade and 3 Commando (Cdo) Brigade. Both these brigades were used to operating independently, within their own operational doctrine and with their own environmental health support (figure 1). While this provided an additional two environmental sections, the different modus operandi did initially cause difficulties in integrating them in the overall divisional environmental health effort.

Another unique fact was the speed of deployment. A force of 46,000 personnel, 28,000 of which were land forces, with equipment, was deployed in just 11 weeks. The potential health issues of moving such a large force from a temperate, barrack environment, to a hot, austere desert environment, with no existing infrastructure are phenomenal.

Phase 1: Force preparation

One of the functions of an EHO staff officer is to input environmental health intelligence on potential environmental health threats, into the general commanding officer's concept of operations (ie how the mission is to be achieved). Medical intelligence includes intelligence on:

• endemic and epidemic diseases, public health standards and capabilities and the quality and availability of health services;
• environmental conditions;
• foreign animal and plant diseases, especially those diseases transmissible to humans;
• health problems relating to the use of local food supplies; and
• hazard threats and risk rating industrial plants in the area of operation.

During the medical planning cycle, the critical issues identified included:

• early entry health issues, particularly field sanitation, water supplies, prevention of heat injuries;
• environmental industrial hazard (EIH) threats from the Iraqi petrochemical industry;
• enemy prisoners of war; and
• refugees.

Concurrently, logistic planning will also be being carried out to evaluate threats that may inhibit support to combat forces, including water, food supplies and sanitation. These functions - the gathering of environmental health intelligence and the formulating of environmental health force protection measures - represent the main environmental health effort during phase 1.

From this intelligence gathering, health defence interventions can be formed to ensure that as far as is reasonably practicable soldiers are protected from the health threats posed by the theatre of operation. For example, medical intelligence showed that there was a malaria risk in southern Iraq between March and September. This triggered a series of interventions ranging from the issue of anti-malarial prophylaxis and the treatment of desert combats with insect repellent, to the training of unit pest controllers and the education of soldiers on biting insect counter-measures.

Medical intelligence combines the disciplines of public health and occupational medicine and on deployments, the medical/environmental health force protection cell will contain specialists in these disciplines. This gives the cell a wide ranging capability and depth of expertise to determine hazards, quantify risks and evaluate controls to inform commanders to enable them to make decisions.

Phase 2: Deployment

Operations begin with the deployment of an organisation called the Joint Force Logistic Component (JFLogC) which deploys with its own EHO and is responsible for carrying out the enabling work required to receive the fighting forces. Enabling work includes a wide range of environmental health functions from building camp infrastructures and initiating waste disposal contracts to setting up port (air and sea) health inspection regimes. To support the JFLogC EHO, there is also a separate environmental health section responsible for the general area environmental health support of incoming units, including the divisional environmental health sections.

Once the JFLogC has deployed, the division will deploy in stages according to a desired order of arrival staff table (DOAST). This ensures, at the basic level, that equipment arrives at the seaport before troops arrive at the airport.

This poses the question of where on the DOAST to put the environmental health sections. Should environmental health technicians (EHTs) be surged in as quickly as possible, or should the deployment be staged to meet emerging health threats, for example humanitarian issues? Doctrine dictates that environmental health personnel are surged in as early as possible and withdrawn as conditions mature. With a potential major refugee crisis and a major environmental health commitment to the regeneration of Iraqi infrastructure, there was a real need for environmental health sections to deploy with sufficient horsepower to enable them to carry out environmental health functions at a high tempo, for the length of the tour.

Phase 3: Conflict

The operation itself was a classic example of manoeuvre warfare - defeating rather than destroying the enemy - with the emphasis on winning the hearts and minds of the Iraqi people to force regime change. This set the theme for the whole tempo of the operation, particularly the rapid transition from phase 3 conflict to phase 4 post-conflict humanitarian aid activities. In fact, at one stage, there were a number of phases running concurrently, with conflict at the front end of the battle space, peacekeeping in the middle ie securing Iraqi medical facilities from looters and humanitarian aid, such as supplying potable water and medicines to local communities, at the rear end.

All military operations involve exposure to risks, both conventional and unconventional. The unconventional includes hazards arising from industrial chemical installations. The UK area of operation is dominated by the Rumaila oilfield and includes numerous well heads, gas oil separation plants (GOSPs), a refinery and petro-chemical plant, storage facilities and above ground crude oil pipelines. This was seen as the major EIH threat to British forces.

Release of toxic chemicals could be by accidental release, collateral damage, and/or deliberate release. These risks will, in many cases, be highly localised and the normal response will be hazard avoidance based on the prior identification, through intelligence, of potential sources of release. However, there will be occasions when the demands of the operation make it impossible to entirely bypass such locations, as in the mission of 16 (AA) Bde to secure the GOSPs, and it is imperative that commanders are made aware of the risks during mission planning.

EIH risks must be managed in line with operational imperatives and the responsibility to generate advice on the potential impact of EIH on operation phases falls to the EHO staff officer (Major Fletcher). It is his function to carry out a form of risk assessment to provide the planners with the information they require to make decisions.

One of the mission parameters of OP TELIC was to take and secure the southern oil facilities and by definition, to achieve the mission, troops would come in contact with EIHs, particularly when clearing installations and securing them from sabotage. Thus, first line responsibility for determining whether an EIH actually existed, or not, lay with advancing troops. On moving into a site, a unit commander will carry out a tactical analysis of all threats to troops, including unidentified chemicals and materials. If an EIH is suspected, this will trigger a further assessment by the environmental health section.

Ideally, sites would be assessed by environmental health sections prior to occupation, but movement constraints close to the front line make this impractical.

In summary, the principles of EIH management are:

• intelligence or information gathering;
• tier 1 risk assessments - these are "quick and dirty" assessments to determine any immediate risks to troops, whether they can be controlled and whether a tier 2 assessment is required;
• control - this may include area evacuation and implementation of exclusion zones; and
• tier 2 assessments - in some cases, the tactical situation may dictate that a certain site has to be manned by troops. If the tier 1 assessment determines that there may be a residual risk and that local area controls cannot reduce the risk to an acceptable level, specialist support can be sought from the UK-based environmental monitoring team (EMT).

Phase 4: Post conflict

Environmental health staff are ideally placed to begin providing immediate humanitarian support in that period between the end of hostilities and the area being safe enough for NGOs to operate in.

To deal with humanitarian issues, the divisional medical group formed a medical consequence management team to carry out health needs assessments of Iraqi medical infrastructures. The team included a wide range of expertise ranging from a pharmacist to environmental health. The assessments not only provided data for NGOs, and governmental organisations such as DFID, but also provided a means to prioritise civil-military co-operation (CIMIC) tasks. In this area, the environmental health sections made a major impact by carrying out rapid structural surveys of Iraqi medical facilities and engaging the appropriate agency, military or civil, to carry out repairs.

In the main, the priority was to restore basic services, particularly potable water and environmental health personnel were crucial in co-ordinating the water delivery chain from point of production, which was at times a Royal Engineer water treatment plant, to point of delivery. Many of the medical facility water tanks required cleaning and disinfecting, and this was achieved by employing local labour as a means generating income for the local community.

Major James Fletcher is presently serving as SO2 Medical Intelligence with HQ 1 (UK) Armoured Division in Herford, Germany.