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May-June 2002 

Conquering Dengue 

Surgeon General of the Navy 
Chief, BUMED 

VADM Michael L. Cowan, MC, USN 

Deputy Surgeon General 
Deputy Chief, BUMED 

RDML Donald C. Arthur, MC, USN 


Jan Kenneth Herman 

Assistant Editor 

Janice Marie Hores 


Andre B. Sobocinski 

Book Review Editor 

LT Y.H. Aboul-Enein, MSC, USN 

NAVY MEDICINE, Vol. 93, No. 3 (ISSN 0895-8211 
USPS 316-070) is published bimonthly by the 
Department of the Navy, Bureau of Medicine and Surgery 
(MED-09H), Washington, DC 20372-5300. Periodical 
postage paid at Washington, DC. 

POSTMASTER: Send address changes to Navy 
Medicine, Bureau of Medicine and Surgery, ATTN; 
MED-09H, 2300 E Street NW, Washington, DC 20372- 

POLICY: Navy Medicine is the official publication 
of the Navy Medical Department. It is intended for 
Medical Department personnel and contains 
professional information relative to medicine, dentistry, 
and the allied health sciences. Opinions expressed are 
those of the authors and do not necessarily represent 
the official position of the Department of the Navy, the 
Bureau of Medicine and Surgery, or any other 
governmental department or agency. Trade names are 
used for identification only and do not represent an 
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Bureau of Medicine and Surgery. Although Navy 
Medicine may cite or extract from directives, authority 
for action should be obtained from the cited reference. 

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Vol. 93, No. 3 
May-June 2002 

Research and Development 

1 Civilian Scientists Go to Sea 
DM. Ryan 

2 Solving a Baffling Mystery: Getting Closer to a Dengue Vaccine 
DM. Ryan 

Department Rounds 

4 New Medical Department Flag Selects 

6 Guantanamo Bay Reflections: Spiritual Readiness and the New War 
CDRK.C. James, CHC, USN 

8 Rescue at any Depth: Navy DMOs Support Undersea Habitat 
CDRR.S. Levine, MC, USN 

10 Space is the Next Port of Call for Navy Docs 
B. Badura 


14 Medical Surveillance Programs for Homeland Defense 
CDR S. Sherman, MC, USN 
CAPTR. Brawley, MC, USN 
MAJJ. Pavlin, MC, USA 
CDR B. Murphy, MSC, USN 

18 Consolidated Medical Check-In: Putting Prevention and 
Readiness First 
LTK. Newman, MSC, USN 

20 Navy Medicine in the Forgotten War: Korea 1950-1953 Part IV 
CAPTE.H. Ginchereau, MC, USNR 

25 Women's History Month Keynote Speaker is RADM Bonnie Potter 
JM. Hores 


24 Navy Medicine Seeks Articles 


26 RADM Walter Welham, MC, USN (Ret.) 

27 C APT Bertha Rae Evans St. Pierre, NC, USN (Ret. ) 

Book Review 

28 The New Biological Weapons: Threat, Proliferation and Control 

A Look Back 

29 Navy Medicine 1945 

COVER: Dr. Shuenn-Jue Wu, senior biologist at the Naval Medical Re- 
search Center, is working to solve the mystery of how dengue viruses 
infect the body. Her goal: To develop an effective vaccine. Story on page 
2. Photo by Phil Collins, MAVS/WRAIR. 

NAVMED P-5088 

Research and Development 

Civilian Scientists 
Go to Sea 

From the laboratory to the deck- 
plate, Navy medicine's re- 
search programs support oper- 
ational readiness, and many Navy re- 
searchers work closely with senior 
medical personnel afloat to carry out 
shipboard studies focused on health 
care delivery. But not all researchers 
have their sea legs. The Bureau of 
Medicine and Surgery (BUMED) 
has a program to help "land-locked" 
scientists and technicians see first- 
hand what work and life is like at sea. 

Mark E. Cohen, Ph.D., a civilian 
research statistician from the Naval 
Dental Research Institute (NDRI), 
Great Lakes, IL, took advantage of 
BUMED's Scientist-to-Sea program 
to set sail aboard USS Yorktown 
(CG-48). Yorktown is the Navy's 
Smart Ship, a guided missile cruiser 
that carries the most sophisticated 
air defense system in the world today, 
the AEGIS Combat System. 

Dr. Cohen said his experiences 
onboard were very educational from 
a technical perspective and extremely 
valuable in gaining an appreciation 
for the challenges and issues facing 
deployed Sailors. He boarded the ship 
in Pascagoula, MS, and spent 5 days 
in the Gulf of Mexico, as Yorktown 
participated in NORAD exercises and 
tested sonar equipment. 

Dr. Cohen was impressed by the 
structured routine and discipline of 

the 360 crew members. "I had no as- 
signed duties, so I was free to roam 
and observe. I spoke with the corps- 
man and discussed dental issues en- 
countered onboard. In the engine 
room, I observed training drills simu- 
lating an emergency as crew members 
were faced with the challenge of com- 
pensating for loss of electrical gen- 
erators, without allowing the whole 
system to shut down. Spending time 
on the bridge, watching the ship be- 
ing navigated, and "shooting" Polaris 
with a sextant with the help of a chief, 
were certainly once in a life time ex- 
periences. I toured the missile com- 
partments, watched the firing of the 
5 -inch and Phalanx guns from the 
bridge, and saw the crew do man- 
overboard drills. This program is cer- 
tainly something unique, and unless 
you are in the military you would 
never get this opportunity. It was an 

As a storm approached, Dr. Cohen 
watched the crew assist the Coast 
Guard in rescuing four fishermen who 
were stranded more than 35 miles 
from shore in a disabled 24-foot open 

He added, "Even though it was 
only 5 days, and my kids are older 
than the young Sailors, I was able to 
begin to imagine the sacrifices that 
Sailors make when they leave their 
families for months at a time. I have 

a better understanding of not only 
what a Sailor does, but what a Sailor 
really is. This is certainly not a typi- 
cal civilian job!" 

CAPT J. Ragain, DC, the NDRI 
commanding officer, pointed out the 
benefit of the BUMED program for 
his staff "All the research conducted 
at the Naval Dental Research Insti- 
tute must be militarily relevant and 
scientifically sound. The Scientist-to- 
Sea Program offers our scientists the 
opportunity to gain first-hand knowl- 
edge of the operational environment. 
The insight they gain by spending a 
few days at sea on the various plat- 
forms is invaluable to us as we de- 
velop our research programs. It is 
imperative that we get out to the 
fleet to ascertain the needs of the 
warfighter, as well as the require- 
ments of the healthcare providers 
who support our Sailors and Ma- 

NDRI is located on the Great Lakes 
Naval Training Center complex. For 
more than 50 years, NDRI research- 
ers have investigated problems related 
to oral health, disease and injury, and 
have developed techniques and prod- 
ucts to improve dental and medical 
care in the Navy. Researchers are cur- 
rently leading the way in developing 
promising salivary diagnostic tech- 
nologies that include non-invasive 
screening methods to detect medical 
conditions such as tuberculosis, den- 
gue fever, and cholera. With the co- 
location of the Army Dental Research 
Detachment in 1996 and the Air Force 
Dental Investigation Service in 2000, 
Great Lakes is now the site for all 
DOD dental research. For more infor- 
mation visit NDRI's website at http:/ 
/ □ 

— Story by Doris M. Ryan, Medical Re- 
search and Development Division (MED-26), 
Bureau of Medicine and Surgery, Washing- 
ton, DC. 

May-June 2002 

Solving a 
Baffling Mystery 

Getting Closer 

to a 
Dengue Vaccine 

Dr. Shuenn-Jue Wu, a Senior Biologist (right) and Ms. Ravithat 
Putvatana (left), Senior Research Assistant at the Naval Medical 
Research Center are working to understand how dengue viruses 
infect the body. 


One bite by a virus-infected 
mosquito while eating lunch 
at an outside cafe, and a 
young Marine stationed in an exotic 
city in the tropics spent 1 week in the 
hospital and 4 weeks in recovery with 
a high fever, rash, severe headache, 
and incapacitating muscle and joint 
pain. For him, it felt like the worst 
case of flu he ever had. For his medi- 
cal team, it was dengue fever. He was 
lucky; this was his first infection with 
dengue virus. The next bite by a den- 
gue-infected mosquito could cause 
dengue hemorrhagic fever (DHF), a 
more severe form of the disease that 
could be fatal. 

There is no cure. Treatment is sup- 
portive — bed-rest, fluids, acetami- 
nophen, and possible hospitalization. 
With aggressive monitoring of vital 
functions and prompt targeted treat- 
ment, the mortality rate can be main- 
tained at 1 percent or less; however, 
illness is severe and recovery requires 

Dengue is caused by one of four 
closely related virus types simply 
called dengue- 1, dengue-2, dengue-3 
and dengue-4. An infection by one 
provides life-long immunity against 
that virus type, but does not provide 
immunity against the other three vi- 
rus types. For some unknown reasons, 
a second infection by one of the other 
three virus types is likely to cause the 
more severe form of disease, or DHF. 

Dengue has been a mystery to sci- 
entists for years, confounding their 
efforts to develop a vaccine. Shuenn- 
Jue Wu, Ph.D., a senior Navy biolo- 
gist, and a team of Navy and Army 
scientists are unraveling the interac- 
tion between the aggressive virus and 
the body's sentinel immune cells 
called dendritic cells. Her team dis- 

covered that the virus targets the den- 
dritic cells, compromising their func- 
tion in the body. The function of a 
dendritic cell is to capture invading 
pathogens, migrate from the skin to 
the regional lymph nodes, or from the 
blood to the spleen, and signal an 
immune response. 

According to Dr. Wu, "Dengue is 
a complicated disease we don't fully 
understand. We were the first re- 
search team to study and prove that 
dendritic cells could be infected with 
the four types of dengue virus. By 
identifying dendritic cells as the first 
target cells we can now mimic a hu- 
man dengue infection using tissue 
culture in the laboratory. We are fur- 
ther evaluating the role of dendritic 
cells in mediating the immune sys- 
tem during dengue virus infection. 
This research opens new windows of 
opportunity and we are excited about 
our potential to progress in develop- 
ing an effective dengue vaccine." 

Using donated blood from human 
volunteers, precursors in blood can 
be collected and dendritic cells 
grown in culture. The culture system 
is a model for researchers to test po- 
tential vaccines against dengue, to 
study the body's immune mecha- 
nisms for fighting infection, and to 
search for clues to solve the mystery 
related to the severity of a second 
dengue infection. 

Dr. Wu published her original re- 
sults in July 2000 in the highly pres- 
tigious Nature Medicine Journal, and 
a photomicrograph of infected den- 
dritic cells from her article was fea- 
tured on the cover of the July 2000 
issue. Dr. Wu's work was recently 
recognized by the Association of 
Military Surgeons of the U.S. 
(AMSUS), a society of federal health 

agencies, and she was selected to re- 
ceive the 2001 AMSUS Sir Henry 
Wellcome Medal and Prize. 

The World Health Organization has 
noted a steady increase in the spread 
and incidence of dengue fever and 
DHF over the past 40 years and now 
dengue is globally recognized as a re- 
emerging infectious disease. Epidem- 
ics have been reported in the Ameri- 
cas, southern Europe, North Africa, 
the eastern Mediterranean, Asia, and 
Australia, and on several islands in the 
Indian Ocean, the south and central 
Pacific, and the Caribbean. 

For the U.S. military, the history of 
dengue has its own story. Dengue in- 
fection was a major cause of incapaci- 
tating febrile illness among American 
troops deployed in the Philippines, 
Asia, and the Western Pacific during 
World War II. In Vietnam dengue was 
the main cause of illness in personnel 
admitted to hospitals who were ini- 
tially diagnosed with fever of un- 
known origin. In Somalia, for "Opera- 
tion Restore Hope," dengue was one 
of the main causes of febrile disease. 
When the Army deployed troops in 
Haiti for "Operation Uphold Democ- 
racy," dengue was the leading cause 
of fever-related hospital admissions. 
The development of a safe and effec- 
tive vaccine against all four types of 
dengue virus to protect deployed 
troops in dengue endemic areas is 
among the Department of Defense's 
highest priorities. □ 

— Story by Doris M. Ryan, Medical Re- 
search and Development Division (MED-26), 
Bureau of Medicine and Surgery, Washington, 

May-June 2002 

Department Rounds 

New Medical Department 
Flag Selections 

CAPT Brian G. Brannman, MSC, 

is currently assigned to the staff of 
the Chief of Naval Operations as Di- 
rector, Medical Resources, Plans 
and Policy Division (N931). 

CAPT Brannman was born in 
National City, CA. Following 
graduation from high school 
in Manhattan, MT, he enlisted in the 
Navy as a hospital corpsman. He 
earned his undergraduate degree in 
health services administration from 
Southern Illinois University, 
Carbondale, IL. In 1979, following completion of a gradu- 
ate degree in management from Webster College, he re- 
ceived a direct appointment into the Medical Service 

During his first commissioned assignment at Naval 
Regional Medical Center, Long Beach, CA, CAPT 
Brannman served as military personnel officer, adminis- 
trative assistant to the director for administration, and 
chief of outpatient administration. In May 1982, he re- 
ported to USS Belleau Wood (LHA 3), where he served 
as medical department head. During the assignment, 
CAPT Brannman achieved qualifications as a surface 
warfare medical department officer. 

CAPT Brannman attended the Naval Postgraduate 
School at Monterey, CA, from June 1984 to December 
1985 where he earned a master of science degree in ad- 
ministrative science (financial management). He subse- 
quently was assigned to the Naval Medical Command 
where he served in the Fiscal Systems Division 

(MEDCOM-13) and later in the Bud- 
get Division (MEDCOM- 1 1). In June 
1988, he joined the staff of the Chief 
of Naval Operations, Resource 
Readiness Appraisal Division (OP- 
81), as an assistant to the executive 
secretary of the Medical Blue Rib- 
bon Panel. Following completion of 
the Blue Ribbon Panel in September 
1988, he reported as the medical pro- 
gram analyst in the General Planning 
and Programming Division (OP- 80) 
where he served until June 1990. In 
July 1990, he reported to Naval Hos- 
pital Long Beach, CA, where he 
served as director for administration. 
Returning to Washington in July 
1992, CAPT Brannman was assigned as deputy budget 
officer at the Bureau of Medicine and Surgery. In June 
1994, he reported to the Office of the Secretary of De- 
fense, where he was the director of programs, on the staff 
of the Deputy Assistant Secretary of Defense (Health 
Budgets and Programs). Beginning in July 1996, CAPT 
Brannman served as executive officer, Naval Hospital 
Bremerton, WA, and concurrently as commanding officer, 
Fleet Hospital, FIVE. He deployed with Fleet Hospital 
FIVE to Haiti from February to August 1997 in support 
of "Operation Restore Democracy/Exercise Fairwinds." 
During CAPT Brannman's last assignment, he served 
as commanding officer, Naval Hospital Okinawa, Japan. 
CAPT Brannman's awards include the Legion of Merit, 
the Defense Meritorious Service Medal, the Meritorious 
Service Medal (four awards), the Navy Commendation 
Medal (two awards), the Navy Achievement Medal, the 
Armed Forces Service Medal, and various service and 
unit awards. □ 


CAPT Thomas K. Burkhard, 

MC, is Fleet Surgeon, Commander 
in Chief, U.S. Naval Forces Europe. 

CAPT Burkhard graduated cum laude from Harvard 
College in 1969 and was commissioned a line 
ensign through the NROTC program. 
His first duty station was aboard the minesweeper USS 
Whippoorwill (MSC-207) homeported in Sasebo, Japan 
on which he performed coastal patrols in South Vietnam. 
In 1971, he attended the Staff Mine Warfare Course at 
Naval Schools Mine Warfare in Charleston, SC, and sub- 
sequently was assigned to the school as an instructor. At 
the conclusion of the Vietnam War, he was attached to 
the staff of Commander, Mobile Mine Countermeasures 
aboard USS New Orleans (LPH- 11) where he participated 
in "Operation ENDSWEEP" clearing mines from North 
Vietnam waters. 

Resigning his line lieutenant commission in Septem- 
ber 1973, he entered duty under instruction at the Uni- 
versity of Connecticut School of Medicine and was com- 
missioned an ensign, United States Naval Reserve. Gradu- 
ating in 1977, he reported to Naval Regional Medical 
Center, San Diego where he completed his internship in 
1978 and a diagnostic radiology residency in 1981. He 
was awarded the Outstanding Senior Resident Award in 
Diagnostic Radiology. Following residency training, he 
was stationed at U.S. Naval Hospital, Guam where he 
served as radiology department head and director for an- 
cillary services. In 1984, he returned to Naval Hospital, 
San Diego as a staff radiologist and was awarded the 
"Golden Ray Award" by the radiology residents as the 
outstanding teacher. Upon completing an imaging fellow- 

ship in 1986, he became assistant chairman of radiology 
and division head for computerized tomography/ultra- 
sound/body MRI. Subsequently, he held the positions of 
director for ancillary services, medical director, and 
deputy commander at Naval Medical Center, San Diego. 
From 1994 to 1996, he was the deputy commander at 
National Naval Medical Center, Bethesda. He com- 
manded Naval Hospital Camp Pendleton from January 
1997 to July 2000 at which time he assumed his current 
position as Fleet Surgeon, Commander in Chief, U.S. 
Naval Forces Europe. CAPT Burkhard served as the Sur- 
geon General's Advisor for Radiology from 1992 to 1995. 
He was appointed clinical associate professor of radiol- 
ogy/nuclear medicine, Uniformed Services University of 
the Health Sciences in 1994 and has co-authored 15 radi- 
ology peer reviewed articles. He received a certificate in 
medical management in 1997 fromTulane University and 
the American College of Physician Executives, and was 
named a certified physician healthcare executive in 1998 
by the American College of Physician Executives. 

His awards include the Legion of Merit with one star, 
Meritorious Service Medal, Navy Commendation Medal, 
Navy Achievement Medal, Combat Action Ribbon, Navy 
Unit Commendation, Meritorious Unit Commendation, 
National Defense Service Medal with one star, Vietnam 
Service Medal with two stars, Humanitarian Service 
Medal, Navy and Marine Corps Overseas Service Rib- 
bon with three stars, Philippine Unit Citation, and Re- 
public of Vietnam Gallantry Cross Unit Citation. □ 

May-June 2002 

Guantanamo Bay Reflections 

Spiritual Readiness and 
the New War 

CDR Kelvin C. James, CHC, USN 

Since 1 1 September 2001, much 
attention has been placed on 
how different our world is be- 
cause of the catastrophic events of 
that day. As our military forces pos- 
tured to fight an illusive enemy, we 
waited daily in anticipation to hear of 
the capture of those responsible. As a 
consequence of those efforts, approxi- 
mately 300 detainees were rounded 
up in Afghanistan and transferred to 
the naval base at Guantanamo Bay, 
Cuba (GTMO). Shortly after the ar- 
rival of the first detainees, a decision 
was made to request the services of 
SPRINT (Special Psychiatric Rapid 
Intervention Team) from Naval Medi- 
cal Center Portsmouth. Our tasking 
was to assist in training personnel 
assigned to Joint Task Force- 160 on 
topics pertaining to stress manage- 
ment, suicide prevention, and spiri- 
tual self-care. Our team arrived on 22 
January to begin our work in train- 
ing, evaluating, and making recom- 
mendations to Joint Task Force- 160 
concerning morale, quality of life, and 
the psychological/spiritual issues af- 
fecting the service men and women 
involved in the operation. Particular 
attention was paid to those personnel 
who were in direct contact with the 
detainees, such as Navy medical per- 
sonnel, Army Military Police guards 
and Marine Corps perimeter watch- 

LT Abuhena Mohammad Saiful-lslam, Muslim chaplain and Imam for the 

The portion of the SPRINT train- 
ing I was responsible for conducting 
was entitled "Spiritual Readiness/Self 
Care." My goal was to ensure that the 
spiritual needs of all personnel were 
met as well as to show how, in this 
new war, we are directly confronted 
with spiritual issues of good and evil, 
which must be effectively addressed 

in order to understand the insidious 
destructive nature of our present en- 

At Camp X-Ray detention site, the 
troops were aware that the detainees 
being guarded were potentially dan- 
gerous and that the detention process 
was a necessary part of our war 
against terrorism. They were con- 


fronted with the incongruity in see- 
ing these same potentially dangerous 
individuals bow reverently in prayer 
five times a day and spend hours read- 
ing the holy text of the Qur'an. With 
the introduction of an imam to the 
operation, LT Abhena Saif Ul Islam, 
a Navy chaplain, who circulated 
among the troops, it became clearer 
to all that the problem was not the 
legitimate and honorable tenants of 
Islam but in misguided beliefs. Ulti- 
mately, as President George Bush has 
pointed out in numerous speeches, 
this is a fight against evil in our world, 
not against religion. 

Interpreted in this way, our present 
situation has specific elements of a 
spiritual struggle which require both 
a spiritual and empirical understand- 
ing. It correlates with the nature of 
our being as body, mind, and spirit. 
Clearly, we know how to keep our 
bodies strong through exercise and to 
cultivate our mental capacity through 
academic pursuits. But what about our 
spiritual dimension? I believe we 
must exercise our spirituality in posi- 
tive, healthy ways as part of our total 
health and emotional well-being. One 
cannot exist without the other. 

Healthy spirituality incorporates 
not only positive spiritual imagery, 
language, and beliefs but actions 
which better humanity and the human 
condition. Its focus is on helping oth- 
ers rather than hurting them. It is hu- 
manitarian in emphasis and not given 
to gross exaggerations, extremist be- 
liefs, or hurtful acts. Positive spiritu- 
ality utilizes the precepts and ideals 
from spiritually healthy, faith-based, 
and value-based belief systems and 
institutions which hold in common 
the admonition to show dignity and 
respect to all people at all times. 

Healthy spiritual development is 
nurtured through relationships which 
foster love, acceptance, forgiveness, 
and a sense of well-being. This in- 

volves connecting with others who 
care about us and are invested in our 
emotional and spiritual growth. It be- 
gins in our family of origin but can 
be enhanced as we go through life 
through participation in practices 
such as prayer, worship, scripture 
study, spirituality groups, and medi- 

As a part of my ministry, I encour- 
aged the troops to be informed about 
their spiritual traditions and the prac- 
tice of their faith because it can make 
a positive difference in all they do. 
My words were met with great enthu- 
siasm. Many of the Soldiers, Sailors, 
Marines, and Coast Guard personnel 
asked about having scriptures avail- 
able to read and inquired daily about 
the various worship services con- 
ducted throughout the base. 

As special religious and cultural 
advisor to Joint Task Force- 160, 
Chaplain Abhena Saif Ul Islam pro- 
vided invaluable exposure, explana- 
tion, and training to the troops at ev- 
ery level. Additionally, the coopera- 
tive presence, availability, and effec- 
tiveness of the Joint Service and base 
support ministry teams, composed of 
chaplains, religious program special- 
ists, chaplain assistants, and religious 
lay leaders underscored the principles 
of teamwork and cooperative plural- 
ism among people of different beliefs, 
demonstrating there can be unity in 

Our troops carried out their duties 
admirably and treated the detainees 
in the most humane way, exhibiting 
the highest respect for the differences 
of culture and faith. They led by ex- 
ample and were more powerful as a 
living model than anything we could 
have said. 

Unquestionably, our armed forces 
and homeland security initiatives are 
committed to dismantling the terror- 
ist network responsible for this 
present war as those responsible for 

the attacks on 1 1 September, and any 
other acts of terrorism, are brought to 
justice. As one young married Seabee 
told me, "Chaplain, I know I'm build- 
ing these detainment units for a good 
cause. And God knows that these 
people had to be stopped. I'm going 
to continue to do my part so that my 
little girl can grow up and board a 
plane safely to fly wherever in the 
world she wants to go. That's why I'm 

In conclusion, when I think of the 
impact that SPRINT had upon the 
young men and women stationed in 
GTMO, I am reminded that our suc- 
cess was predicated on the fact that 
we operated as a team in every way. 
By adopting a holistic approach to our 
training and in evaluating the needs 
of the troops, we were able to bring 
to the table the rich perspective and 
expertise of our various disciplines to 
address the needs of the whole per- 
son — body, mind and spirit. 

It was an experience I will always 
remember, because from it I wit- 
nessed first hand the positive results 
that can occur when working in a 
highly stressful military environment 
with a team of exceptionally gifted 
individuals totally committed to pro- 
fessional excellence in all they do and 
are. The level of cooperation and pro- 
fessionalism at GTMO also under- 
scored the special partnership that 
exists between the military medical 
community and the chaplain commu- 
nity in support of military operations 
throughout the fleet and the world in 
MTFs, on deployment platforms, and 
in units of all kinds. Working beside 
my medical colleagues at Camp X- 
Ray gave new meaning to Navy 
medicine's motto: Charlie-Papa ... 
Steaming to Assist. □ 

CDR James is the Deputy for Pastoral 
Care Services and staff chaplain at Naval 
Medical Center, Portsmouth, VA. 

May-June 2002 

Rescue at 
Any Depth 

Navy DMOs 

Support Undersea Habitat 

Aquarius in Wilmington, NC, after refurbishment 
and just prior to relocation in the Florida Keys 

CDR Ross S. Levine, MC, USN 

This past year, Naval Diving and 
Salvage Training Center (ND- 
STC) and National Undersea 
Research Center (NURC)/University 
of North Carolina at Wilmington 
(UNCW) entered into a formal agree- 
ment whereby NDSTC provides a 
diving medical officer (DMO) for the 
medical support of saturation diving 
missions in the habitat Aquarius. 

Aquarius is an underwater ocean 
laboratory located in the Florida Keys 
National Marine Sanctuary The labo- 
ratory is deployed 3-1/2 miles off- 
shore, at a depth of 60 feet, next to 
spectacular coral reefs. Scientists live 
in Aquarius during 10-day missions 
using saturation diving to study and 
explore our coastal ocean. Aquarius 
is owned by the National Oceanic 
and Atmospheric Administration 
(NOAA) and is operated by the 

When the possibility of Navy 
DMOs acting as the diving medical 
experts for some "civilian" underwa- 
ter saturation missions down in Key 
Largo, FL, was first mentioned, I 
thought the likelihood of getting all 
the details and legal issues worked out 

was quite small. But with the persis- 
tence of Craig Cooper (NURC), the 
support of Barbara Moore and Steven 
Miller of UNCW, and the support of 
NDSTC Commanding Officers CDR 
Mark Helmkamp and then CDR Jon 
Kurtz, the proposal became a reality 
and a unique training opportunity. 

We just completed our first season 
of cooperation with Aquarius and it 
was an outstanding success: seven 
saturation missions and seven DMOs 
gaining new experience in saturation 
diving medicine. Aquarius' personnel 
were exceptionally pleased and said, 
they "never were as comfortable or 
had such excellent medical support 
prior to our involvement." 

Each mission is divided into three 
phases: training, saturation, and de- 
compression. Every phase has its own 
particular medical issues that require 
attention and/or may be problematic. 
I would like to briefly discuss each 
of these phases. 

Phase one is training. The crew 
prepares the habitat for the mission 
and the scientists are trained in stan- 
dard and emergency procedures for 
living in and diving from the habitat. 

During this phase, the DMO reviews 
the health records and dive physicals 
of all potential aquanauts and deter- 
mines their suitability for saturation. 
Our agreement requires that the div- 
ing candidates be pre-screened by 
NOAA/UNCW to ensure they meet 
NOAA standards for diving. These 
standards are close to the intent of 
Navy diving standards but may not 
meet their exact letter. For example, 
one candidate had a total hip replace- 
ment in the last year. Though prob- 
ably not a candidate for Navy diving 
as his original problem was Degen- 
erative Joint Disease and not Avas- 
cular Necrosis, we saw no reason to 
disqualify him as an Aquanaut. 

There was a circumstance where 
one of the DMOs did disqualify a can- 
didate. Upon screening his record and 
physical examination he discovered 
a history of 2mm ST depression on a 
recent exercise stress test, and a cal- 
cium CT scan which revealed 2 dif- 
ferent 50 percent LAD lesions. The 
cardiologist felt his chances of a ma- 
jor cardiac event were "low." His ex- 
ercise tolerance was adequate for rou- 
tine diving. If he experienced chest 


Aquarius is deployed at a depth of 63 feet adjacent to deep coral 
reefs in the Florida Keys National Marine Sanctuary 

pain or an arrhythmia during a bounce 
dive, he could likely be surfaced 
quickly and treated. The same might 
not be true if he were saturated at 45 
feet. Not only would it take 16 hours 
for him to surface, but, defibrillation 
in the habitat is not currently possible. 
Hence, this candidate did not saturate 
and the team was pleased with our 

Phase two is the actual saturation 
that lasts from a minimum of 6 days 
to a maximum of 14 days depending 
upon the mission. In this phase the 
scientists become saturated with air 
at a habitat depth of 45-47 feet (de- 
pending on tide). From here they con- 
duct their scientific mission. This in- 
cludes multiple "excursions" outside 
the habitat for a maximum of 360 
minutes per day. Upward excursions 
are possible, but ascent and time are 
limited and generally not performed. 
Similar to diving from 1 atmosphere, 
downward excursions are limited de- 
pending upon depth. 

During this phase the DMO is re- 
sponsible for assuring diver fitness is 
maintained throughout the dive and 
for any medical treatment deemed 
necessary during the mission. While 
the DMO does not live in the habitat 
and saturate, it is during this phase 
that the DMO makes daily "habitat 
calls" to check on the aquanauts. Typi- 

cal problems during this 
phase include treatment 
of cuts and bruises, up- 
I per respiratory infec- 
tions, and a plague of 
I ear infections and skin 
: disorders secondary to 
p the high humidity and 
g perfect primordial petri 
dish conditions. Obvi- 
ously, more severe 
problems are possible. Serious trauma 
or decompression illness secondary to 
an accidental blowup or upward ex- 
cursion is possible, but not likely. 

Phase three is decompression. 
Prior to this phase the scientific work 
ends and all excursions outside the 
habitat are completed by 1000 hours 
the day of decompression. Typically 
the DMO makes a final visit to the 
aquanauts for any final issues or prob- 
lems. At the same time a diving medi- 
cal technician (DMT) from the 
topside crew enters the habitat. He ad- 
ministers oxygen when the aquanauts 
begin their decompression with three 
20-minute 100 percent oxygen peri- 
ods, and he helps "drive" the cham- 
ber (the habitat) for the remainder of 
decompression. Decompression be- 
gins at 1600 and ends at 0800 the fol- 
lowing morning — a 45 -foot ascent 
over 16 hours. Now at 1 atmosphere 
in the habitat, but still 45 feet below 
the surface, the aquanauts re -pressur- 
ize in a short "bounce dive" back to 
45 feet. Then they don scuba gear and 
swim to the surface. 

While the DMT functions as the 
inside eyes and hands, it is ultimately 
the DMO who is responsible for di- 
agnosis and treatment of any decom- 
pression illness that occurs while trav- 
eling back to 1 atmosphere. Due to 
the painstakingly slow ascent, the 

likelihood of barotraumas, POIS (pul- 
monary over inflation syndrome), or 
AGE (arterial gas embolism) is vir- 
tually negligible. On the other hand, 
Type I or II decompression illness is 

While research and saturation div- 
ing still takes place at the Navy Ex- 
perimental Diving Unit in Panama 
City, FL, the Navy has not regularly 
been involved in platform saturation 
diving since the Sealab project in 
1969. As a result, this aspect of div- 
ing medicine has been virtually lost 
from the repertoire of the current gen- 
eration of Navy DMOs. (Coinci- 
dently, the Navy was involved with a 
41 -day saturation mission on USS 
Monitor this past summer.) The op- 
portunity provided by our agreement 
with Aquarius is invaluable from both 
a professional skill and an experience 
point of view. 

This season, we look forward to 
expanding our involvement with the 
habitat by sending additional person- 
nel for training and support of these 
missions. More ambitiously, we hope 
this will be the beginning of a long 
and fruitful relationship that may be 
the launching platform to get the Navy 
involved once again with platform 
saturation diving. □ 

For further information about training 
in diving medicine or these missions, 
please contact Dr. Ross Levine in the 
medical department at Naval Diving 
and Salvage Training Center: 
850-235-5247; DSN: 436-5247. 

Dr. Levine is Senior Medical Officer at 
the Naval Diving and Salvage Training 
Center, Panama City, FL. 

May-June 2002 


is the 


Port of 


for Navy Docs 

CAPT Lee Morin 

In this time of transition for our 
nation, the military has been thrust 
to the forefront of the news. The 
media routinely highlights the works 
of our naval forces stationed 24 hours 
a day onboard ships, in remote field 
locations, and at shore stations around 
the globe. But how much media cov- 
erage focuses on our shipmates train- 
ing to serve in an environment con- 
sidered by many to be out of this 

For a few successful Navy profes- 
sionals, their skills, career experi- 
ences, and a little luck cultivated an 
opportunity that most of us have prob- 
ably dreamed of at some point. Their 
ship actually flies and their duty sta- 
tion is with the National Aeronautics 
and Space Administration (NASA). 

CAPT Lee Morin, MC, CDR Lau- 
rel Clark, MC, and CAPT Dave 
Brown, MC, three of the Navy's fin- 
est flight surgeons, are participating 

in two of this year's missions with the 
Space Shuttle program as mission 

Traditionally, the Navy's role is 
identified as an integral part of our 
national defense. Navy astronauts, 
however, are part of the offense due 
to the research they conduct as part 
of the space program. Much of the 
work done on the ground seeks to 
answer tough questions or find solu- 
tions to scientific problems. While all 
astronauts share common experiences 
in training, their missions, STS-110 
and STS-107, have distinctly differ- 
ent flavors. 

Brown and Clark are scheduled to 
launch in July aboard STS-107. Dur- 
ing their 16-day mission, the focus 
will be on research and the Navy doc- 
tors will be very busy. As mission 
specialists, they have overall respon- 
sibility for payloads and experiment 
operations, as well as training in the 

details of the onboard systems. Their 
medical expertise makes them well 
suited to conduct what NASA refers 
to as "life science" experiments. 

NASA will be flying bone cells and 
prostate cancer cells together for the 
first time, looking at the biochemical 
signals between them that enhance or 
are involved in the transmission of 
prostate cancer early and aggressively 
to bone. The hope is that the experi- 
ment and observation will offer an 
understanding of this process in or- 
der to help advance the development 
of a therapy. "Prostate cancer doesn't 
kill people, it's the bone metastases 
that kill people," Clark said. 

Brown will spend some time con- 
ducting physical science experiments 
related to combustion research and 
soot emissions. In a microgravity en- 
vironment, combustion does not act 
in the same way as on earth, allowing 
researchers a different perspective on 



its basic characteristics. "In 
microgravity, a flame has no distinct 
shape, because gravity is what gives 
it the shape that we are familiar with," 
Brown explained. By studying soot 
emissions, researchers hope their 
findings help identify methods that 
can be used to curb their rapid ex- 
pansion. "People throughout the 
world burn fires and our projects will 
hopefully help with the reduction of 
soot, which is a major pollutant," he 

STS-107 will be bustling with ac- 
tivity for the entire duration of its 
mission, with many projects on 
board. Medical research will also 
look at protein turnover and calcium 
kinetics when humans are exposed to 
microgravity. Four crew members 
will be studied before, during, and 
after the flight, to try to answer the 
question of why microgravity con- 
tributes to bone loss. 

Another medical experiment will 
grow stromal bone cells inside a 
bioreactor. This equipment is also 
used on earth to grow cell cultures. 
"The advantage of growing the cells 
in space is that it more closely repli- 
cates the production of cells in the 
human body," Clark explained. Other 
studies will assess the effects of an- 
tibiotics on different strains of bac- 
teria at a cell and cell culture level. 

"We will also be doing some re- 
search for a group of Dutch scientists 
who are trying to treat patients who 
have trouble with their blood pres- 
sure when they stand up," noted 
Brown. This condition, known as 
orthostatic hypertension, affects as- 
tronauts for a few hours after a flight. 
The Dutch scientists will examine the 
astronauts immediately after landing 
to help further their studies related 
to this problem. 

In contrast to STS-107 and its re- 
search focus, with STS-110, Morin 

CDR Laurel Clark 

and other members of the crew con- 
centrated on the continued construc- 
tion of the International Space Station 
(ISS). Time in orbit was much shorter, 
with only 10 days to complete as- 
signed tasks. 

The STS- 1 10 orbiter Atlantis spent 
the majority of its time in orbit docked 
with the ISS to facilitate the addition 
of new structural elements. The crew 
installed the first piece of a large truss 
that will eventually be hundreds of 
feet long and hold the solar arrays that 
provide electrical power for the sta- 
tion modules. This first section just fit 
in the shuttle's cargo bay, at about 40 
feet long, and weighed about 30,000 

Installing the truss required the per- 
formance of four extra-vehicular ac- 
tivities (EVA) or space walks. Morin 
made two EVAs, installing two struts 
that help support the main truss. Other 
related tasks included installing con- 
figurations and cables along with fel- 
low mission specialist, Jerry Ross. 
The EVA with Ross marked a small 
milestone in NASA history. "Our 
space walk was the first with two 
grandfathers," he remarked. 

Working in space presents a whole 
new set of challenges for astronauts. 
Morin is quick to point out that work- 
ing in microgravity does have some 
connections with his medical past. 
"It's a lot like sterile technique in the 

May-June 2002 


operating room, where you have a 
protocol that you follow in terms of 
levels of protection and handling of 
equipment," he said. "Actions must 
be very disciplined, almost deliberate, 
even when you're getting tired." 

Losing equipment while floating in 
space can pose a great risk to the mis- 
sion. "Space debris is a real hazard, 
because with orbital mechanics, it 
may be moving away from you and a 
half hour later, it comes back and 
bangs into you," he said. "In addition, 
you may lose a critical tool to do your 

To help compensate for these dif- 
ficult working conditions, NASA has 
designed every dial, knob, and tool 
to be user friendly and efficient. They 
also acclimate astronauts to EVA-like 
conditions by training them in the 
Neutral Buoyancy Laboratory (NBL) 
at Johnson Space Center. The lab 
houses a large water tank that helps 
to simulate microgravity conditions, 
and is named after a fellow Navy 
flight surgeon and astronaut, the late 
CAPT M.L. "Sonny" Carter. "Other 
people who have been in space have 
said that you feel right at home after 
this training," said Morin. 

Morin also continued the further 
development of on-orbit exercise 
equipment that aims to help people 
stay fit while living in microgravity. 
Additionally, he acted as the crew 
medical officer, tending to any medi- 
cal needs that arose. 

"One great challenge in rendering 
medical treatment in space is how the 
patient is restrained in a microgravity 
environment. To administer CPR, you 
basically stand on the ceiling and push 
down against the patient's chest," he 

Some may ask what the advantages 
of doing research in space are, espe- 
cially considering that time is limited, 
quarters are tight and costs are high. 

CAPT David Brown 

Brown offered some interesting in- 
sight, "Science typically tries to con- 
trol variables and change one, but in 
microgravity you can actually elimi- 
nate some variables. By eliminating 
variables, it allows researchers to un- 
derstand very basic fundamental 
physical principles and that's why you 
go to space," he said. 

Before being assigned to a specific 
mission, astronauts spend years in 
training and evaluation. As an ex- 
ample, Clark, Brown, and Morin were 
selected as part of the 1996 astronaut 
class, but 2002 marked the first time 
any of them traveled in space. The 
application process includes a stack 
of paperwork and competition is 

Naval personnel have been a large 
part of the astronaut program, with 96 
out of 310 astronauts selected com- 
ing from the Department of the Navy, 
according to NASA records. Seven of 
those have been flight surgeons. 
"Navy involvement in the space pro- 
gram dates back to the original seven 
astronauts in 1959," said Duane Ross, 
manager of the astronaut selection 
office at NASA. In fact, the first 
American in space, the late Alan 
Shepard, retired as a Navy rear admi- 

When evaluating candidates, 
NASA looks at applicants who can 
bring a broad base of skills and abili- 
ties. "The thing we look at when we 
evaluate a candidate is good opera- 



tional experience and how applicable 
the experience may be," explained 
Ross. "Just a clinician is probably not 
what we're looking for. Doc Brown 
flew jets, Laurel did a lot of work with 
divers, and Lee is an absolute genius 
and can build just about anything." 

To say this trio is an accomplished 
group is certainly not an overstate- 
ment. Each one of them brings a di- 
verse skill set gathered from working 
in very challenging environments. 

Morin appears to have an insatiable 
appetite for education. To comple- 
ment his doctorate of medicine de- 
gree, Morin's educational background 
includes a doctorate of microbiology 
and a master of public health. He is 
qualified as a diving medical officer 
as well as a submarine medical of- 
ficer. During his career, Morin has de- 
veloped software used in a multi-lin- 
gual voice translator and he wrote 
much of the 5,000 plus pages of soft- 
ware that STS-1 10 employed. 

Operational experience has been 
familiar territory for Clark. She has 
been on numerous deployments, in- 
cluding one to the Western Pacific. 
Clark also spent time assigned to Sub- 
marine Squadron Fourteen in Holy 
Loch, Scotland. Her military qualifi- 
cations are diverse, including radia- 
tion health officer, diving medical of- 
ficer, submarine medical officer, as 
well as naval flight surgeon. Medical 
accomplishments include advanced 
trauma life support provider and hy- 
perbaric chamber advisor. 

From the time he was a young boy, 
Brown dreamed of flight. "I still re- 
member my first airplane flight, 
watching the wheels while we rolled 
down the runway so I could tell the 
exact moment we were airborne," he 
noted. After joining the Navy as a 
physician, Brown completed flight 
surgeon training and spent some time 
on deployment in the Western Pacific. 

In 1988, Brown was the only flight 
surgeon to be selected for pilot train- 
ing in a 10-year period. He graduated 
number one in his class and earned 
his designation as a naval aviator. 
During his career, CAPT Brown has 
logged over 1 ,700 hours in high per- 
formance military aircraft. He also 
owns two airplanes and operates them 
from an airstrip located behind his 

For Clark, Brown, and Morin, the 
choice to apply to the program was 
natural once they found they met the 
criteria of a qualified applicant. "Once 
I was aware of the space program, it 
was an easy thing to apply," Clark 
said. For Brown and Morin, the space 
program was a logical transition in 
their careers. "I was a flight surgeon, 
then flew jets, so I saw the space pro- 
gram as the next greatest challenge," 
Brown explained. All three are very 
satisfied with their choice to join one 
of the world's leading scientific and 
operational communities. "I felt that 
if I had never applied, I would always 
wish that I had," said Morin. 

As missions draw near, personal 
time for astronauts becomes very lim- 
ited. "Once you get assigned, you set 
aside pretty much all of your hobbies 
and interests to get ready for the mis- 
sion," said Morin. Clark shared an 
analogy that most Navy personnel can 
understand. "It's like the time before 
a deployment. You're not thinking 
about your recreation time or softball 

Each had a uniquely different an- 
swer when recalling a favorite point 
in the training program. 

• For Clark: "Going to Russia to 
train for weightlessness in their 0G 
aircraft. That was wonderful." 

• For Brown: "Riding bicycles 
through the tulip fields outside 
Amsterdam during our time training 
with Dutch researchers." 

• For Morin: "Seeing the vehicle 
that we were actually going to fly, 
climbing around on it in bunny suits, 
and realizing that it wasn't a model." 

Although it may take years to re- 
turn to space after their missions are 
over, the three Navy doctors look for- 
ward to the opportunity. CAPT Morin 
sums it up best, "We'll worry about 
first things first, but I hope I get a 
chance to go again. Right now, there 
are over 100 astronauts and the num- 
ber of flights will only be about four 
per year." 

The space program may seem like 
a lofty goal to some, but for Laurel 
Clark, Dave Brown, and Lee Morin, 
their hard work and success through- 
out their careers helped to open doors 
in ways they never imagined. "I feel 
very fortunate to be where I am. Some 
of it was due to career choices but 
some of it is simply good fortune," 
Clark noted. 

When asked what advice they 
would pass on to Navy colleagues or 
anyone who might want to follow in 
their footsteps, one should reference 
the emphatic philosophy of Dave 
Brown for guidance. "If you get an 
idea in your head that there is some- 
thing you really want to do, just go 
do it. You have to live your life today 
and do the things that are right for 
you," he said. "If the path opens up 
to other things, then that's great. But 
don't ever underestimate yourself."Q 

— Story by Brian Badura, Public Affairs 
Specialist (MED-00P3), Bureau of Medicine 
and Surgery, Washington, DC. 

May-June 2002 



Medical Surveillance 



Homeland Defense 

CDR Scott Sherman, MC, USN 
CAPT Robert Brawley, MC, USN 

MAJ Julie Pavlin, MC, USA 
CDR Brian Murphy, MSC, USN 

Since the tragic attacks of 11 
September, the Military Health 
System, civilian caregivers, 
and public health professionals have 
been given a mandate to try to en- 
hance the nation's ability to rapidly 
detect disease outbreaks. Capturing 
health surveillance data can help to 
identify the "who, what, when, and 
where" if disease rates start to in- 
crease. Several systems are starting 
to emerge. Three types of these sys- 
tems are currently in use in Navy hos- 
pitals and operational units and can 
be quickly adapted, as appropriate, to 
track trends in local patient popula- 
tions to enhance homeland defense 

One of the classic problems in epi- 
demiology is how to sort out the "nor- 
mal" background rate of disease from 
"epidemic disease," disease that is 
occurring at an elevated rate in the 
population. Accordingly, the first 
three generally accepted steps in al- 
most any epidemiological investiga- 
tion are to establish a case definition, 
confirm the presence of the epidemic 
using this case definition, and then to 
verify the diagnosis in patients that 
appear to fit the case definition. As 
the remainder of the outbreak inves- 
tigation is completed, the object is to 
find the key places to intervene to in- 
terrupt the outbreak. In the United 
States the Centers for Disease Con- 

trol and Prevention (CDC) has an 
Epidemic Intelligence Service (EIS) 
that specializes in these types of "dis- 
ease detective" investigations - see The EIS was 
initially formed to prepare a cadre of 
public health officers to learn to sort 
out "man-made" versus "naturally oc- 
curring" epidemics, an important cold 
war concern at its founding in 1951. 
Because of the nature of military 
service, the Navy also has a cadre of 
personnel that can perform these same 
epidemiological investigations. Pre- 
ventive medicine technicians, envi- 
ronmental health officers, preventive 
medicine physicians, infection con- 
trol practitioners, and infectious dis- 



ease physicians have received addi- 
tional training in detecting and insti- 
tuting preventive measures to stop 
intentional or naturally occurring epi- 
demics. Small numbers of these per- 
sonnel are attached to various com- 
mands. Outside consultation can be 
obtained by calling the Navy Environ- 
mental Health Center (NEHC) or one 
of its subordinate public health units 
the Navy Environmental and Preven- 
tive Medicine Units (NEPMUs) lo- 
cated in Norfolk, San Diego, Pearl 
Harbor, and Sigonella. (see http:// 

For analysis of probable epidem- 
ics, commands can directly ask for a 
small investigation team from their lo- 
cal NEPMU. If the need is for a ro- 
bust capability, then OPNAV-931 can 
be asked to task the deployment of a 
Preventive Medicine Mobile Medical 
Augmentation Readiness Team 
(PM-MMART). Several of these 
deploy able 12-person teams exist 
around the world and offer a compre- 
hensive package of epidemiology, en- 
vironmental health, microbiology, 
entomology, and industrial hygiene 
capability. These teams have the abil- 
ity to rapidly identify a wide range of 
biological, radiological, and chemical 
threats using standard military test 
kits, portable mass spectrography, and 
polymerase chain reaction (PCR) or 
immunochromatographic test kits. 

During our last combat campaigns 
in Operations Desert Shield/Storm, 
Navy preventive medicine personnel 
attached to the Marines started the 
modern era of disease surveillance in 
military units by implementing a sys- 
tem that was adopted by a wartime 
Commander-in-Chief (CINC) to 
monitor disease and injuries in his 
theater. These personnel were the first 

to show that disease and non-battle 
injury (DNBI) surveillance informa- 
tion could be effectively captured and 
used each week to guide public health 
interventions in a large deployed 
ground force. This early system used 
a "stubby pencil" method to capture 
information that was entered into a 
spreadsheet program and then briefed 
to key operational decision makers. 

New patient complaints were to- 
taled and grouped each week in each 
unit by "plain language" syndrome 
category (i.e. respiratory, diarrhea, 
dermatological, ophthalmologic, 
STD, fever, etc.). This system was the 
first to document the mission-abort- 
ing diarrhea and respiratory disease 
rates in some operational units early 
in the campaign. The impact of DNBI 
on mission readiness set the frame- 
work for subsequent line decisions to 
take appropriate force health protec- 
tion actions and establish preventive 
medicine priorities of action. The suc- 
cess of this system in protecting ele- 
ments of the 1st Marine Expedition- 
ary Force during Desert Shield/Storm 
and subsequent operations in Opera- 
tion Restore Hope was the basis for 
subsequent DNBI surveillance re- 
quirements for operational forces. 
The Navy physician who spearheaded 
these efforts, then LCDR Kevin 
Hanson, received the first-ever Chair- 
man of the Joint Chiefs of Staff Award 
for Military Medicine from GEN 
Colin Powell acknowledging the im- 
portance of this medical information 
to line decision-making. 

In response to the September 
terrorist attacks and the October an- 
thrax bioterrorism events, epidemi- 
ologists at NEHC developed a modi- 
fication of this operational DNBI sur- 
veillance system, called the Rapidly 

Deployable Surveillance System 
(RDSS). RDSS was designed to en- 
able Navy MTFs to quickly establish 
an "active" syndromic surveillance 
system for acute infectious diseases 
that could potentially be caused by 
biological warfare agents. Naval 
Medical Center Portsmouth was the 
first command to implement RDSS 
and now has ongoing surveillance in 
14 area locations. The basic approach 
in RDSS is to count the number of 
people presenting in the emergency 
department and the primary care clin- 
ics each day in five syndromic cat- 
egories (consistently using either 
chief complaint or final diagnosis) — 
dermatological, respiratory, infectious 
gastrointestinal, ophthalmologic, and 
unexplained fever. At the end of each 
shift or at least once each day these 
numbers are tallied for each clinic and 
then shared with the clinic personnel 
and the preventive medicine depart- 
ment. If unusual changes are noted an 
attempt is then made to explain what 
may be happening and to alert the 
patient care staff to look for an ex- 
planation of the trends. 

The benefit of the system is that it 
can be tailored to meet each hospital 
or clinic's needs and it provides some 
teaching value since it is based on the 
JCS-required system for certain de- 
ployed units. Its major limitation is 
that it requires some additional effort 
on the part of the infection control and 
preventive medicine staff to track the 
data, and the clinics may have to 
modify their patient processing pro- 
cedures to effectively capture the ap- 
propriate syndromic counts. 

Unknown to many hospitals and 
clinics in the wake of 11 September, 
a passive electronic data capture sys- 
tem called ESSENCE that had been 

May-June 2002 


running in the National Capital Re- 
gion (NCR) was expanded to include 
all DOD medical treatment facilities. 
The Electronic Surveillance System 
for the Early Notification of Commu- 
nity Based Epidemics (ESSENCE) 
was developed in 1999 by the Depart- 
ment of Defense's Global Emerging 
Infections Surveillance and Response 
System (DOD-GEIS) (see http:// in response to 
its mandate under Presidential Deci- 
sion Directive NSTC-7 on emerging 

ESSENCE started with a goal of 
establishing a sensitive, specific, 
timely, standardized, flexible health 
indicator surveillance system for the 
National Capital Region. Since its 
implementation, ESSENCE has fo- 
cused on the acquisition, statistical 
analysis, and posting via secure 
website the aggregated daily Ambu- 
latory Data System (ADS) data from 
about 104 MHS primary care clinics 
and emergency rooms in the NCR. 

Each day since the fall, expansion 
ESSENCE has extracted all ADS data 
submitted from all MTFs throughout 
DOD. This includes ADS data from 
121 Army, 110 Navy, 80 Air Force, 
and 2 Coast Guard installations world- 
wide. For each ADS-coded visit, these 
records include an ICD-9 code, the 
date the visit occurred, the MTF, and 
several other pieces of information. 
Each of these records is tabulated by 
MTF, date, and "syndrome group." 
These procedures are performed anew 
daily for each MTF and for each ES- 
SENCE-defined geo-cluster. The to- 
tal count of visits for a particular day 
is compared to a threshold calculated 
from that particular MTF's or cluster's 
historical experience. When the count 
exceeds the threshold, that MTF and 

syndrome group is posted on the ES- 
SENCE site. This is a secure, pass- 
word-protected site that is available 
to appropriate medical personnel by 
contacting the NEHC Preventive 
Medicine Directorate to obtain the 
URL and password for ESSENCE, 
they can be reached at 757-953-07 10/ 
0707, the DSN prefix is 377. 

At the present time, data from all 
MTFs are visible to all users enabling 
quick comparisons for similar prob- 
lems in other MTFs in the same re- 

ESSENCE'S principal advantages 
are that it is currently up and running, 
shows data from all DOD treatment 
facilities (enables regional compari- 
sons), and requires no additional "ac- 
tive" surveillance work to implement. 
Its principal limitations are that it re- 
lies on ADS data that is only as good 
and timely as the ADS coding and 
then the system process that enters 
them. As an example, it is possible 
that ADS records may not be entered 
until Friday, say, for visits that oc- 
curred on Tuesday, or even longer 
after the visits occurred. It may be that 
these "late" ADS records push the 
MTF count for several days ago over 
the threshold of concern resulting in 
a new "alert" level for the past Tues- 
day that may be several days delayed 
before it is recognized. 

The third system that is currently 
active in two MTFs and has been in- 
volved in extensive testing in certain 
deployed operational units is the 
Medical Data Surveillance System 
(MDSS). This software was devel- 
oped jointly by the Naval Health Re- 
search Center (NHRC) and the Space 
and Warfare Command Systems Cen- 
ter (SPAWAR) San Diego. This prod- 
uct draws on the same type of data as 

the ESSENCE system, but does it 
from within the MTF. For ambulatory 
encounters the patient identifier and 
the ICD-9 code are captured and 
mapped to a plain language category 
description similar to the ESSENCE 
system. Using signal processing ap- 
proaches borrowed from quality con- 
trol, sonar and infra-red imagery com- 
munities, the program detects burst 
and trend statistical changes in the di- 
agnoses or numbers of patients pre- 
senting for care and then color-codes 
"alerts" based on the site's recent his- 
tory (5-8 previous days) using a trend 
analysis sub-program called Dynamic 
Changepoint Detection (DCD) devel- 
oped at SPAWAR Systems Center San 
Diego by Jamie Pugh. 

MDSS color codes a display of the 
original input data based on the com- 
bined output of these statistics. Red 
and black coding alerts the user to the 
probability of a statistically signifi- 
cant event. Yellow coding is a cau- 
tion warning that an outbreak may be 
emerging and should be watched. The 
color-coding system also marks the 
estimated start and end of potential 
events, thereby providing investiga- 
tive information to the staff. In addi- 
tion to these ESSENCE category 
maps, MDSS can "reverse engineer" 
an estimate of certain key symptom 
groups, "ill-defined" symptom clus- 
ters, and operational unit disease and 
non-battle injury (DNBI) category 
counts. MDSS also allows for 2x2 
contingency table analysis, data ex- 
port to a spreadsheet, and summary 
reporting of notifiable diseases. 

The principal advantages of MDSS 
are its use of color-coded (based on 
severity of trend) automatic alerting 
threshold and change detection algo- 
rithms, flexibility to accept user modi- 



fications, ability to adapt to SAMS or 
other individual clinical data feeds, 
ability to locally "drill down" to the 
individual patient encounter record, 
and removal of some time delay and 
potential firewall problems since it 
only operates within its MTF. Its prin- 
cipal limitations are that it requires 
additional network server capacity 
and a separate system install at each 
facility that wants to use it, reliance 
on ADS data mentioned in the ES- 
SENCE limitations, and it does not 
allow for wide geographic compari- 
sons between MTFs (unless their 
ADS data is maintained by the same 
computer system or is moved to a cen- 
tral server). 

Whether your command chooses 
the active "shoe leather" epidemiol- 

ogy approach of the RDSS, the pas- 
sive global online monitoring of the 
ESSENCE system, or the MTF-based 
analytic capabilities of the MDSS 
program, one of these methods — or 
some combination of them — can 
quickly move your MTF and Navy 
medicine into a key role to enhance 
homeland defense. Implementation of 
these systems now, when coupled 
with aggressive monitoring of senti- 
nel laboratory results and the report- 
ing of notifiable diseases through the 
local community public health sys- 
tem, NEHC, and your cognizant 
NEPMU, will give Navy medicine the 
information it needs to identify un- 
usual outbreaks of natural or man- 
made disease at the earliest opportu- 
nity. We will then be able more effec- 

tively to target interventions to pro- 
tect our patients and communities and 
Navy medicine's goal of Force Health 
Protection. If you've been looking for 
a legitimate medical use for those 
ambulatory care "bubble sheets," now 
you've got one! □ 

CDR Sherman is assigned to Navy Envi- 
ronmental and Preventive Medicine Unit No. 
5 San Diego and is President, Navy Epidemi- 
ology Board. 

CAPT Brawley is assigned to Navy Envi- 
ronmental Health Center Portsmouth, VA. 

MAJ Pavlin is assigned to the Walter Reed 
Army Institute of Research (WRAIR), Wash- 
ington, DC. 

CDR Murphy is assigned to the Naval 
Health Research Center, San Diego, CA. 

Attention Navy Medicine Readers 

The Bureau of Medicine and Surgery Library and Archives is collecting historical material relating to 
the Navy Medical Department. Main items of interest include magazines, books, photographs, and 
slides. If you have items that you are willing to donate please contact us (telephone:202-762-3244 or 
3248; e-mail: ) 

May-June 2002 


Consolidated Medical 


Putting Prevention 
and Readiness First 

LCDR James C. Gay, NC, USN 
LT Kelly Newman, MSC, USN 

No one would argue that there are a lot of admin- 
istrative and clinical demands placed on primary 
care providers and their staffs. Intended to ben- 
efit patients and clinicians, the balance between demand, 
readiness issues, documentation, prevention, and the 
patient's goals can seem contradictory and overwhelm- 
ing. In addressing this apparent conflict, we developed 
and implemented a consolidated medical check-in pro- 
cess that streamlined these requirements while maintain- 
ing prevention, medical readiness, and patient centered 
care at the forefront. 

Originating in Rota, Spain as a means of documenting 
new arrival screening, the check-in process at that time 
was primarily a means of verifying Overseas Screening. 
This check-in process was further developed by Naval 
Hospital Cherry Point and became the enrollment tool 
for their Family Practice Clinic. 

In Okinawa the operational component and the elec- 
tronic Health Evaluation and Assessment Review 
(HEAR) survey were added to provide a complete health 
maintenance process called the consolidated medical 
check-in. An SF-600 overprint is the documentation tool. 
Similar screening tools developed for units with and with- 
out the HEAR are available upon request by contacting 
LCDR Gay at or LT 
Newman at or 

Implemented at the Futenma Branch Medical Clinic, 
the consolidated medical check-in process was greeted 

with significant and early success. Subsequently, the pro- 
cess was adopted by all branch medical clinics on 
Okinawa as a USNH Okinawa Population Health Im- 
provement Working Group initiative. When tailored to 
meet local operational requirements, this process has 
proven to be a highly effective tool for managing the 
healthcare of active duty personnel and their family mem- 
bers. Units have passed their Functional Area Inspections 
with minimal preparation, medical readiness has signifi- 
cantly improved, chronic medical conditions are ad- 
dressed when the patient reports, and the patients are very 
satisfied. The following delineates this process step by 

• All newly arriving patients are given a 45-minute 
Primary Care Manager (PCM) appointment as their 

• New labels are printed for bar code tracking of the 
health record and the "full registration" and demographic 
information is entered into the Composite Health Care 
System (CHCS). 

• Sections 1-7 of the Adult Preventive and Chronic Care 
Flow Sheet (DD Form 2766) are updated. 

• The patient takes the electronic HEAR Survey. If 
unavailable, an interview is conducted. 

• While the patient is taking the survey a nurse or hos- 
pital corpsman screens the medical record for the docu- 
mented medical history, required immunizations, ongo- 
ing therapy, deficient screening exams, and required readi- 



ness tests. Health record maintenance is completed and 
if the patient does not have a health record, one is cre- 
ated. Privacy acts are signed and occupational health 
screening reports updated. 

• PCM by name and TRICARE paperwork is com- 
pleted and forwarded to the TRICARE office. This is im- 
portant for personnel transferring between commands on 
the island. 

• The hospital corpsman or nurse then reviews the 
HEAR survey results and health record with the patient. 
Any deficiencies such as required labs and immuniza- 
tions are corrected the same day. Patients are routed 
through the lab, immunizations, physical exams, audi- 
ometry, preventive medicine, and appointment clerk as 
indicated. These sections have been physically reorga- 
nized to streamline patient care (one stop shopping). If 
conditions requiring a medical officer evaluation are iden- 
tified, a PCM appointment is made. If deemed urgent, 
the patient is seen that same day. 

• The screening tool or HEAR survey is filed in the 
health record. 

• Mandatory training in smoking cessation, environ- 
mental risk factors, STD prevention, and prophylaxis, 
cancer prevention, drug and alcohol dependence, and 
depression, is conducted and documented. 

• Patients receive a tour of the clinic and are given age 
appropriate Put Prevention into Practice (PPIP) handouts 
including a list of local health resources and support 
groups. The patient is also informed as to clinic hours 
and policies as well as how to access the clinic. This in- 
cludes local websites, phone systems, and appointment 

• The medical record is then sent to the provider as- 
signed as PCM for review and concurrence. Based on 
the credentials of the provider and the health needs of 
the patient, the appropriateness of the PCM assignment 
is reviewed and corrected if needed. 

• The patient is advised to schedule a regular appoint- 
ment during their birth month for routine health mainte- 

nance, testing, and immunizations, referred to as their 
"birth month review." 

• Once the check-in process is completed, the record 
is filed in the records room. If the patient is an active 
duty member, the record is reviewed by his or her unit 
corpsman and readiness data entered into the unit Snap 
Automated Medical System (SAMS). 

The benefits to the unit are that personnel are always 
operationally "Ready" without the need for mass immu- 
nizations or catch up programs. Time away from the unit 
to accommodate recurring, predictable health mainte- 
nance tests, and immunizations is reduced to one visit 
per year. Chronic health needs are addressed when the 
member reports and early intervention is afforded for 
acute problems. Numerous health concerns were also 
detected that would not otherwise have been addressed. 

The clinics noted that the demand for acute care de- 
creased significantly while access to appointments as 
measured by TRICARE access standards increased. Epi- 
sodic care decreased with pro-active and preventive care. 
This change in demand allowed the clinics to increase 
the time afforded providers for routine appointments with 
a significant increase in provider satisfaction. Compli- 
ance with Ambulatory Data System (ADS) coding, real 
time patient documentation, and provider to patient con- 
tact increased dramatically. 

This highly innovative check-in process effectively 
marries operation and preventive health requirements and 
assists with the implementation of OPNAV 6210.3 PRE- 
increased operational readiness, higher quality patient 
visits with their PCM, and a decrease in man-hours lost 
to visits with medical. In addition, both provider and pa- 
tient satisfaction were increased. It is anticipated that a 
current and accurate baseline health status will facilitate 
post deployment evaluations of active duty personnel. □ 

LCDR Gay is Division Officer for the Ambulatory Procedure Unit, 
USNH, Okinawa. 

LT Newman is Officer in Charge of Evans Medical Clinic, USNH, 

May-June 2002 


Navy Medicine 

in the 
Forgotten War 

Korea 1950-1953 
Part IV 

CAPT Eugene H. Ginchereau, MC, USNR 

The Panmunjom peace negotia- 
tions, which had begun on 25 
October 1950, continued 
throughout much of 1952 without the 
resolution of seemingly irreconcilable 
issues. Agreements on the military de- 
marcation line and demilitarized zone, 
and the repatriation of prisoners of 
war (POWs) remained unsettled. Of 
the two, the transfer of POWs was the 
most intractable since many of the 
prisoners in the United Nations Com- 
mand (UNC) internment camps re- 
fused to be repatriated to North Ko- 
rea. The Communists insisted on the 
transfer of all POWs; the UNC coun- 
tered that the transfer should be vol- 
untary. The deadlock on this issue led 
to a suspension of the peace talks on 
28 September 1952. 

The deadlocked talks coincided 
with the military stalemate. UNC su- 
periority in firepower and logistics 

Medical personnel provide emergency treatment to a 
Marine shot through the throat at a receiving hospital 
near Seoul. 



LT J.H. Smith, DC, USN, prepares to 
extract a Marine officer's lower molar. 

was evenly matched by Communist 
superiority in manpower. Each faced 
the other over a line that stretched 
across the waist of the Korean penin- 
sula, roughly coinciding with the 38th 
Parallel, the pre-war partition line 
between North and South Korea. Nei- 
ther side was willing to commit men 
and material to large-scale offensive 
operations as conducted in 1950- 
1951. The conflict became a war of 
position, a type of warfare that re- 
sembled the trench warfare of World 
War I. Under the direction of General 
Mark Clark, who replaced General 
Matthew Ridgway as UNC Com- 
mander in May 1952, United Nations 
forces executed incessant small unit 
actions to consolidate and protect the 

main battle line. These short fierce 
encounters with the enemy in raids on 
outposts, ambushes, and patrols led 
to many casualties in 1952.(7) 

Marine Operations in West Korea 

During March 1952, the 1st Ma- 
rine Division transferred from east- 
ern to western Korea to anchor the 
left flank of the U.S. Eighth Army and 
to block any Communist Chinese and 
North Korean advance on Seoul. As 
part of I Corps, the Division defended 
approximately 35 miles of frontline 
entrenchments. In early August, while 
attempting to protect the strategic 
positions assigned to it, the Division 
fought the Battle of Bunker Hill, a 
series of intense firefights on and 

around Hill 122. On 13 August 1952, 
the first of four hospital corpsmen to 
receive the Medal of Honor for hero- 
ism in western Korea was killed in 
action. Hospitalman John E. Kilmer 
died heroically protecting a wounded 
Marine from exploding mortar 

Besides the large number of 
wounded Marines requiring evacua- 
tion and treatment during the Battle 
of Bunker Hill, Navy doctors, nurses, 
and hospital corpsmen were con- 
fronted with an increasing number of 
heat casualties. The high temperature 
and humidity of the South Korean 
summer combined with vigorous ac- 
tivity and use of the heavy armored 
vest caused many Marines to experi- 
ence heat exhaustion. Despite this 
added risk of wearing the vests, few 
Marines were willing to abandon the 
protection that had saved the lives of 
at least 17 Marines in the battle. (4) 

May-June 2002 


The Battle of Bunker Hill was fol- 
lowed by a period of continuous com- 
bat that lasted until November when 
winter forced a lull in the fighting. 
1952 ended in Korea much as it had 
begun — stalled negotiations and 
stalemate on the ground. 

Advances in Combat Casualty Care 

By 1952, the men and women of 
Navy medicine were operating the 
most advanced, effective system of 
combat casualty care ever deployed 
in warfare. This achievement trans- 
lated into plunging death rates for 
wounded Marines. In fact, the death 
rate of 2 percent for wounded Marines 
participating in the Battle of Bunker 
Hill was the lowest for any battle 
fought by the Marines since the war 

Many innovations in medical 
evacuation and treatment interacted 
synergistically to lower the morbid- 
ity and mortality rates of the wounded 
as the Korean War progressed. Heli- 
copter transport of the wounded in- 
troduced during the first year of the 
war became the preferred method of 
evacuation from the battlefield. Most 
wounded Marines were able to re- 
ceive definitive surgical care within 
10 minutes of being wounded. 

Blood for treatment of shock was 
available in large amounts. In Octo- 
ber 1952, a record number of 1,328 
pints was transfused. During the war, 
an average of 700 pints per month for 
every 1,000 casualties was used. (6) 

The regimental clearing and col- 
lecting companies were converted 
into frontline surgical hospitals in 
1952. These field hospitals operated 
within 4 miles of the main battle line, 
offering sophisticated on-call surgi- 
cal procedures. Laparotomies, thora- 
cotomies, craniotomies, and arterial 

John J. Muccio, U.S. Ambassador to South Korea (right), 
CAPT Edwin B. Coyle, MC, USN, commanding officer of the 
hospital aboard USS Repose (AH-16), and LT Roberta 
Ohrman, NC, USN, look in on a Marine patient. 

repairs were routinely performed. 
Between 1 January 1952 and 1 Janu- 
ary 1953, 2,247 major operations and 
3,235 minor operations were com- 
pleted at the front.(7) 

The frontline surgical hospitals 
were supported by hospital ships — 
floating treatment facilities with 
medical and surgical capabilities 
equivalent to a large naval hospital. 
Equipped with helicopter platforms, 
the hospital ships, like their land- 
based counterparts, could expedi- 
tiously receive and treat the most 
complex of combat wounds. During 
their service in Korean waters, Navy 
hospital ships treated approximately 
20,000 casualties.(S) 

Surgeons became more knowl- 
edgeable and skilled in the techniques 
of wound care. Early debridement and 
delayed closure became the standard 
for extremity wounds. This new ap- 
proach produced satisfactory wound 

healing in 95 percent of the cases and 
reduced the rate of amputation to a 
minimum. (9) 

The first field vascular repair pro- 
gram in the history of warfare was 
created. The availability of fresh ho- 
mologous arteries allowed vascular 
surgeons to repair popliteal artery in- 
juries at the front and dramatically 
lower the amputation rate of legs, a 
common complication of these 
wounds. The substitution of arterial 
grafting of the injured popliteal artery 
for simple ligation reduced the rate 
of amputation from 70 percent or 
more to 37 percent. (10) 

The management of serious head 
wounds became an intractable prob- 
lem after the introduction of the ar- 
mored vest. Marines who otherwise 
would have died of chest wounds 
were surviving and presenting to 
frontline surgeons with complicated 
neurosurgical injuries. The need for 



prompt surgical intervention com- 
pelled Navy neurosurgeons to rede- 
fine combat neurosurgery by perform- 
ing the most difficult neurosurgical 
procedures ever attempted in a com- 
bat zone. 

An Election of Hope 

Americans prayed that the Christ- 
mas of 1952 would be the last Christ- 
mas of the war. They were beginning 
to sense that the country was involved 
in a meaningless war that seemed to 
have no end. Discouragement, frus- 
tration, and anger grew as did the 
daily casualty count. 

Disgruntlement over the impasse 
in Korea contributed significantly to 
the victory of GEN Dwight D. Eisen- 
hower in the presidential election of 
November 1952. Eisenhower had 
promised during the election, "If 
elected, I will go to Korea," and he 
did in December 1952. With "Ike" in 
charge, many believed that the war 
would end soon. 


1. Between April 1952 and December 
1952, the 1st Marine Division experi- 
enced 7,841 casualties (960 deaths). See 
LCOL Pat Meid, USMCR and MAJ 
James M. Yingling, USMC. Operations 
in West Korea. In U.S. Marine Operations 
in Korea, 1950-1953, V. (Washington, 
DC: Historical Division, Headquarters, 
U.S. Marine Corps, 1972), p. 573. 

2. Ibid, p. 127. 

3. John E. Kilmer was a distant cousin of 
Joyce Kilmer, the World War I poet who 
was killed in action 30 July 1918. See 
Meid and Yingling, P. 127. 

4. Meid and Yingling, p. 140. 

5. Ibid, p. 140. 

Marines turn captured North Korean 
medical equipment over to Navy medical 

6. The History of the Medical Department 
of the United States Navy, 1945-1955. 
NAVMED P-5057, p. 172. 

7. Ibid, p. 171. 

8. Ibid, p. 181. 

9. Ibid, p. 175. 

10. Ibid, p. 175. 


Field, JA., Jr. History of United States 
Naval Operations: Korea. Washington, 
DC: Government Printing Office, 1962. 
The History of the Medical Department 
of the United States Navy, 1945-1955. 
NAVMED P-5057. 
Meid, P., Yingling, JM. Operations in 

West Korea. In U.S. Marine Operations 
in Korea, 1950-1953. 5 vols. Washing- 
ton, DC: Historical Division, Headquar- 
ters, U.S. Marine Corps, 1972. 
Sandler, S. The Korean War: No Victors, 
No Vanquished. Lexington, KY: Univer- 
sity Press of Kentucky, 1999. 
Toland, J. In Mortal Combat: Korea, 
1950-1953. New York: William Morrow 
and Company, Inc., 1991. □ 

Dr. Ginchereau is Director of Occupational 
Health Services, St. Francis Health System, 
Pittsburgh, PA. He is assigned to Fleet Hos- 
pital, Fort Dix, NJ, Det. 01. 

May-June 2002 


Navy Medicine Seeks Articles 

W'hile many quality articles are submitted to Navy Medicine, we are constantly looking for greater 
diversity. Because Navy medicine is a dynamic, changing institution, we would especially like this 
journal to provide an opportunity for the free exchange of ideas, opinions, and innovations. There is 
no one topic that assures publication, but here are some general topics we would like to see more of: 

1. Research - cutting edge research of both a professional and clinical nature. We are also interested in 
research articles geared for the lay reader. 

2. History - historical articles related to Navy medicine. 

3. Unusual experiences - first person accounts of current events, such as the "War Against Terrorism" or 
other deployments, and natural disasters. Third person accounts are also encouraged as they generally add a 
broader perspective. Even if these articles are not published, informative pieces will be accessioned into the 
BUMED Archives for research purposes. 

4. Opinion - thought-provoking editorials and opinions on whatever you feel is important: for example, 
downsizing - how do current military reductions affect Navy medicine; the future - what does the future por- 
tend for Navy medicine (fleet health support, dependent care, TRICARE, Readiness, Optimization, Integra- 
tion, etc.), and the individual corps. 

5. Professional/Clinical articles - when writing professional/clinical articles, remember that the aspect of 
care or innovative practice should be unique or particularly relevant to Navy medicine, i.e., treatment of tropi- 
cal diseases which afflict Navy personnel during deployments. 

Editorial Guidelines 

Submissions should be 1,000 to 2,000 words double-spaced. Include a 3-1/2 inch disk in one of the follow- 
ing formats: WordPerfect 6.1 or Microsoft Word. Please be sure to include the full name, rank, and affiliation 
of all authors, a contact telephone number, military address, and email address. In the case of more than one 
author, please provide all of the above information for all the authors, but select one contact representative. 


Photos should, whenever possible, be black and white 8" x 10", captioned, and with photographer noted for 
credit purposes. Quality photography is essential. Snapshot photos, Polaroids, or those not properly focused 
and exposed cannot be used. Exceptional photos related to any aspect of Navy/Marine Corps medical practice 
are always in demand for possible cover use. No color slides and/or large transparencies please. Digital images 
must be made with high resolution quality equipment. Whenever possible digital photos should be printed in 
hard copy format on quality photographic paper. 

Tables and figures should be fully marked and camera-ready. References should be properly footnoted, and 
the manuscript should have a bibliography if outside sources were used. For the proper format of references 
and bibliographies please consult a recent copy of Navy Medicine. □ 

Send submissions for consideration to: 

Janice M. Hores, Assistant Editor 


Bureau of Medicine and Surgery 

2300 E St. N.W. 

Washington, DC 20372-5300 


IjIflPlllmiA |ll| llJfari.ii 


Women's History 


Keynote Speaker is 

RADM Bonnie Potter 

On Tuesday, 26 March, BUMED's Multinational 
Awareness Committee hosted its annual Women's 
History Month Program. The theme was "Women Sus- 
taining the American Spirit," and the speaker was RADM 
Bonnie B. Potter, MC. RADM Potter is the first Navy 
woman physician to be promoted to flag rank. 

VADM Michael Cowan, Surgeon General of the Navy, 
opened the program which featured highlights from the 
lives of four women in military history: Dr. Mary E. 
Walker, Virginia Hall, Dr. Edith Cavell, and Dr. Eliza- 
beth Blackwell. 

RADM Potter opened her address by pointing out that 
being asked to speak at women's history celebrations "is 
a great opportunity to learn more about our history, and 
the many achievements of women over the years, while 
also recognizing some of the obstacles they had to over- 
come along the road to success." 

RADM Potter recalled applying for a Navy Health Pro- 
fessional scholarship 30 years ago and looking forward 
to going to sea as a general medical officer as her father 
had done in World War II, only to find upon graduation 
in 1975 that because of her gender she was ineligible to 
serve aboard ship. She also spoke of her concern whether 
a career for her as a female Navy physician was even 

Dr. Potter went on to profile some women who were 
ground breakers in the military: 

Deborah Sampson, who disguised herself as a man and 
joined the Continental Army during the Revolutionary 
War. Sampson enlisted under the name of Robert 
Shirtliffe, served for 3 years, and was wounded twice, 
caring for her own wounds to avoid detection. Only after 
she contracted brain fever and was rendered unconscious 
did a physician discover her true gender. To protect her 
secret, he cared for her in his own home. Years later, a 
special bill was passed awarding Sampson a pension for 
her services as a revolutionary soldier. 

Then there is the story of the legendary Lucy Brewer, 
who is said to have been the first woman Marine. A Mas- 

sachusetts farm girl who ended up in Boston during the 
War of 1812. Brewer was inspired by the Deborah 
Sampson story. She also disguised herself and joined the 
Marine Corps as George Baker, serving on the USS Con- 
stitution and participating in some of the bloodiest sea 
battles of the war. 

Dr. Potter spoke of Dr. Elizabeth Blackwell, the first 
woman to receive a medical degree in the U.S., and Dr. 
Mary E. Walker, only the second woman to graduate from 
a U.S. medical school. Unable to join the Union Army as 
a physician during the Civil War, Dr. Walker enlisted as 
a nurse. Two years after her enlistment, she was finally 
granted assistant surgeon rank, becoming the first female 
medical officer. Dr. Walker was awarded the Medal of 
Honor for her Civil War service. 

There was not much advancement for women in the 
military until after 1900. Dr. Potter pointed out that sig- 
nificant strides were made with the creation of the Army 
Nurse Corps in 1901 and the Navy Nurse Corps in 1908. 
In her own experience, at least, she didn't have to pre- 
tend to be a man or serve as a nurse, despite the fact that 
the doctor's lounge in one treatment facility where she 
worked was actually the men's room. 

Change took a huge leap in 1972 when Chief of Naval 
Operations, ADM Elmo R. Zumwalt, Jr., issued his Z- 
Gram #116 which stated: "My position with respect to 
women in the Navy is that they have historically played a 
significant role in the accomplishment of our Naval mis- 
sion. However, I believe we can do far more than we 
have in the past in according women equal opportunity 
to contribute their extensive talents and to achieve full 
professional status. Moreover, the imminence of an all 
volunteer force has heightened the importance of women 
as a vital personnel resource. I foresee that in the near 
future we may very well have authority to utilize officer 
and enlisted women onboard ships." 

The Navy has not been the same since, nor will it be 
again. Zumwalt authorized: 

• command ashore for women. 

• the entry of enlisted women into all ratings. 

May-June 2002 


• assigning a limited number of women to the USS 
Sanctuary (AH- 17) as a pilot program. 

• accepting applications from women officers for the 
Chaplain and Civil Engineer Corps. 

• directing increased opportunity for women's profes- 
sional growth by directing the assignment of women to 
the full spectrum of billets. 

• equalizing the selection criteria for naval training by 
opening midshipmen programs to women at all NROTC 

• the selection of women to the National War College 
and Industrial College of the Armed Forces. 

But the most dynamic impact of Z-Gram #116 was 
that its ultimate goal was the assignment of women to 
ships at sea. Since that day, the destiny of women in the 
Navy has traveled forward, if not in leaps and bounds, 
steadily with major milestones: 

• In 1973 CAPT Alene Duerk, Director of the Nurse 
Corps, became the first woman to be promoted to flag 

• There are now 270 female Navy pilots, with over 
7,000 women in aviation ratings. 

• Women now attend the Naval Academy. 

• Over 20,000 women are now assigned to 150 ships. 

• Women are now selected for command at sea and 
assigned to combatant ships. 

• Women now comprise 14.6 percent of the active duty 
Navy force. 

When Dr. Potter is asked about her secret to success, 
she likes to refer to GEN Colin Powell's now famous 
response: "There are no secrets to success. Don't waste 
your time looking for them. Success is the result of per- 
fection, hard work, learning from failure, loyalty to those 
for whom you work, and persistence." 

Dr. Potter doesn't measure success by rank or posi- 
tion, but rather by doing the best we can and liking our- 
selves in the process. Success is measured by demon- 
strating honesty, integrity, and commitment. Success is 
assured when we don't wait for things to be handed to us 
but by "blooming where we are planted" and walking 
through the door of opportunity when it opens. Success 
means doing the right thing in the face of adversity and 
finding balance in our lives. But most importantly, Dr. 
Potter defines success not as a destination but an unend- 
ing journey. — JMH 


In Memoriam 

RADM Walter Welham, MC, 
USN (Ret.), who served as ex- 
ecutive director of the Association of 
Military Surgeons of the United 
States (AMSUS) from 1970 to 1984, 
died 24 March 2002. He was 94. 

A native of Philadelphia, PA, Dr. 
Welham attended the University of 
Pennsylvania, and in 1935 graduated 
from Temple University Medical 
School. He entered the Navy Medi- 
cal Corps in August 1936 and was as- 
signed to Naval Hospital Philadel- 

Beginning in January 1939, 
RADM Welham instructed subma- 
rine medicine courses at the Deep Sea 
Diving School, Washington, DC. He next served as medi- 
cal officer on the staff of Commander Service Squadron 
SIX. In July 1941 he reported as assistant medical of- 
ficer with the Experimental Diving Unit, Washington, DC, 
where he was on duty when the United States entered 
World War II. 

During World War II, RADM Welham served in both 
the Pacific and Atlantic theaters as a senior medical of- 

ficer. In the closing years of the war 
he reported as medical officer on the 
staff of Commander Submarine Force, 
U.S. Pacific Fleet. 

Other tours of duties included 
medical officer on the staff of Com- 
mander Submarine Force, U.S. Pacific 
Fleet and U.S. Atlantic Fleet, and se- 
nior medical officer at the U.S. Naval 
Academy, Annapolis, MD. 

On 16 August 1963 Dr. Welham be- 
came Assistant Chief of the Bureau 
of Medicine and Surgery for Research 
and Military Medical Specialties. In 
October 1964 he assumed duty as 
Fleet Surgeon on the staff of the Com- 
mander in Chief, U.S. Pacific Fleet. 
In 1970 RADM Welham was elected to direct AMSUS, 
an organization established in 1891. He held that post 
until 1984. 

RADM Welham's awards include the American De- 
fense Medal; campaign medals for the Asiatic-Pacific 
Theater with campaign star, and the European-Mediter- 
ranean Theater; World War II Victory Medal; National 
Defense Medal; and the Legion of Merit. — ABS 



Bertha Evans St. Pierre (right) and Margaret Nash celebrate their 
liberation in March 1945. 

And Then There Were None 

CAPT Bertha Rae Evans St. Pierre, NC, (Ret.) died 
on 22 October 2001, shortly after celebrating her 
97th birthday. She was the last survivor of the 11 
Navy nurses held captive by the Japanese in the Philip- 
pines during World War II. 

CAPT St. Pierre graduated from Good Samaritan 
School of Nursing and joined the Navy 4 years later upon 
the recommendation of her brother E.E. Evans, a Navy 
doctor. After a 6-month indoctrination program at Naval 
Hospital Mare Island, CA, that consisted of on-the-job- 
training with a senior nurse on one of the hospital's wards, 
she did a 2 year stint at Naval Hospital San Diego. She 
then entered The George Washington University, Wash- 
ington, DC, to study nutrition. While on assignment at 
Naval Hospital Canacao, the Philippines, St. Pierre and 
1 1 other Navy nurses soon found themselves at war. On 
10 December, the Cavite Navy Yard was bombed to rubble 
and she and the entire hospital staff worked day and night 
to treat hundreds of civilian and military casualties. 

After the Japanese captured the Philippines, St. Pierre 
and 10 of her fellow Navy nurses became prisoners of 
war and were interned at Santo Tomas and then Los Banos 

prison camps for 3 arduous years.* Despite the lack of 
food and medicine, she continued to work in the prison 
hospitals treating many fellow internees until the Los 
Banos prisoners were liberated in a dramatic rescue in 
February 1945. 

Following liberation, St. Pierre returned home and re- 
mained in the Navy, retiring in 1955. 

She subsequently married and moved to Portland, OR, 
to be near her family. 

Like her fellow nurse POW comrades, Bertha Evans 
St. Pierre survived her captivity because she never lost 
sight of her mission — to care for her patients regardless 
of the circumstances. Following World War II, former 
Navy Nurse Corps Superintendent, CAPT Sue Dauser, 
said of St. Pierre: "Every nurse I have spoken with who 
was imprisoned with her never misses an opportunity to 
speak of their admiration. She seems to have been the 
one person who has won the hearts of them all." 

CAPT St. Pierre was awarded the Bronze Star for her 
World War II service.— ABS 

*LT Ann Bernatitus made it to Bataan and was successfully 
evacuated from Corregidor before the island fell to the Japanese. 
She was the only Navy nurse in the Philippines to elude capture. 

May-June 2002 


Book Review 

The New Biological Weapons: Threat, Proliferation and 
Control by Malcolm Dando. Lynne Rienner Publishers. 
London, United Kingdom, 2001. 181 pages. 

Many current books on biological and chemical weap- 
ons typically devote a single chapter to the future 
of weapons of mass destruction. This book looks at the 
theoretical aspects of bio-weapons research that could 
have an impact in the future. 

Dr. Dando is a professor of international security at 
the University of Bradford in the United Kingdom. Al- 
though his specialty is international relations and arms 
control, he received his undergraduate degree in biol- 
ogy. He has had a lifelong interest in chemical and bio- 
logical weapons (BW), writing two previous books, Bio- 
logical Warfare in the list Century in 1994, and A New 
Form of Warfare in 1996. With a grant from the United 
States Peace Institute, this third book explores a new 
generation of biological weapons. These are agents that 
not only target bio-regulators within the human body con- 
trolling respiratory rate but also disrupt nerve transmit- 
ters that control information and responses emitted from 
the brain and spinal column. 

The author also discusses dual use technology such as 
the quest by pharmaceutical companies to find efficient 
means of delivering medicine aside from injection. This 
has led to comprehensive research into the manufacture 
of drugs to be inhaled and absorbed through the lungs. 
The bio- weaponeer is not far behind actual developments 
in medical science. Delivering life-saving drugs effec- 
tively by inhalation also means an opportunity to develop 
a BW agent that is efficiently absorbed through the lungs. 
There are many current forms of BW that cause harm 
only if inhaled. The book contains many examples of 
dual-use technology, so a nation claiming to open a fac- 
tory to develop pharmaceuticals also has the technology 
to mass-produce BW agents. 

Mapping the human genome (DNA) opens the door 
to curing diseases prevalent in certain ethnic groups. It 
can also stimulate research in ethnic BW weapons as a 
means of conducting ethnic cleansing. 

The first chapters look at a historical development of 
two types of BW — toxins and bio-regulators. Among the 
items highlighted is the search for an agent that is easy to 
produce and store, is robust upon dispersal, and has 
known predictable effects on the victim. The United 
States found two toxins that met these characteristics 
botulinum toxin and staphylococcal enterotoxin B (SEB). 
Botulinum is a killer and SEB an incapacitator. Research 
on these substances began as early as 1943. 

The United States abandoned its BW program in the 
1970s but third world nations intent on a BW program 
have seized upon both this research and that done by the 

former Soviet Union, providing these nations with a head 
start; many technical problems have already been over- 
come. In 1991 a UN Special Commission report on Iraq 
found 122mm rocket and artillery shells along with Al- 
Hussein missile warheads filled with botulinum, anthrax, 
and aflatoxin. 

The research in botanical bio-regulators emerged from 
studying plant defoliant during the Vietnam War. Basic 
herbicides could be developed to target plant hormones 
that stimulate stem elongation, cell division, and growth, 
as well as germination of seeds. 

This new realm of potential research in B W using ge- 
netic engineering is of grave concern. The author points 
to a U.S. Defense Department technical annex located in 
the 1997 publication Proliferation: Threat and Response 
to further articulate this point. While mentioning classic 
B W agents of concern, it highlights the enormous poten- 
tial of altering this technology with the use of modern 
molecular biology. Among the set of new agents that could 
be produced through advances in genetic engineering are: 
micro-organisms resistant to antibiotics, standard vaccines 
and therapy; micro-organisms with enhanced aerosol and 
environmental stability; and immunologically altered mi- 
cro-organisms able to defeat standard identification, de- 
tection, and diagnostic methods. 

The author cites the writings and lectures of Soviet 
defector Ken Alibek, former head of the Soviet B W pro- 
gram. Alibek attended a 1989 meeting in which a speaker 
announced successful animal trials of inserting a myelin 
toxin in a bacterial host. The infected animal developed 
both the disease and a paralysis resulting from the toxin 
attacking the myelin sheath around the nerves. A single 
genetically engineered agent had produced the symptoms 
of two different diseases, one of which could not be traced. 

The book continues with potential research in altering 
human bio-regulatory peptides that control blood pres- 
sure, respiration, body temperature, and a dozen other 
functions. Although in a theoretical and research stage as 
far as BW development, the Canadians have expressed 
concern regarding former Soviet experimentation in this 
field. Malcolm Dando points out these potential misuses 
of biological technology and the drive by unstable re- 
gimes to develop such weapons. He highlights Iraqi in- 
terest in ethnic weapons and postulates the fixation with 
aflatoxin as a means of causing long-term liver damage 
to the Kurds — a form of primitive and subtle ethnic geno- 
cide. The final chapter makes a compelling argument re- 
garding the inadequacies of current arms control trea- 
ties. Such agreements have not kept pace with techno- 
logical development, thus making the complex issues of 
enforcement even more challenging. □ 

— LT Aboul-Enein is studying at the Joint Military Intelligence 
College in Washington, DC. He is a designated Middle East 
Foreign Area Officer. 



A Look Back 

Navy Medicine 1945 

With the battle for Okinawa not yet won, a wounded Marine is transferred from jeep 
ambulance to a waiting "grasshopper" aircraft for evacuation. 

May-June 2002