A discussion of planning factors for medical deployments

1. Deployment Medicine
Frank Meissner, MD, FACP, FACC, FCCP
LtCol, USAF, MC, FS
Chief of Cardiology

2. What is the Mission?
●Peacekeeping
●Conventional Combat Operations
●Special Operations
●‘Nation Building’- ‘MedCaps’

3. Who will be the Patients?
●US Military Personnel
●Multi-National Force - Peacekeepers
●Indigenious Populations
●Refugees

4. Who is the Boss?
●US Line
●US Medical
●Multi-national Commanders

5. What resources & WHO controls
them?
●Tents vs Fixed Installations
●Local Medical Resources
●Evacuation Routes and Methods
●Supply and Logisitics

6. What is the Tactical Situation?
●Security of facility- Paramount Concern
●Will you need to re-deployment?
●Do you need to augment defense?
●Electronic security/ECM
●Escape and Evasion Plan

7. What is the ‘Threat”
●Endemic Diseases
●Epidemic Diseases
●Veneral Disease
●CBR Threat?
●Practical Traumatology

8. Resources - An Example From
Zagreb
●Medline Search - Croatia, Serbia
Keywords
●AFMIC BBS - Disease and threat files for
ALL 35 Nations assigned to Croatia
Command
●CIA Factbook Via Internet Croatia,
Serbia, Macadonia
●Croatia Usenet Group

9. Computers in Zagreb
●LAN WorkGroup- Combat Trauma Life Support
●E-mail via LAN Mailserver
●Clinical & NETWORK News
●CD-ROM References
●Modem Slide File for Presentation
●ER DataBase Access via Telnet Zagreb-Texas

10. Computers in Zagreb
●Listserver Continuing Medical Education
●Clinical Discharge Summaries
●Communication in High Ambient Noise
Environment
●Email exchange of Critical Data/Consulations
●ACLS/ATLS Simulators

11. Case #1
●3 wk hx/o progressively decreased visual
acuity OS
●Intense puritius X 2 months
●Native Kenya from RURAL region near
running water
●In Croatia X 9 mo’s

12. Exam/Laboratory
●Eczematoid dermatitis &leg
hypopigmentation
●Sclerosing keratitis of inferior temporal
quadrant cornea OS
●Visual Acuity 20/20 OD & 20/200 OS
●90% Eosinophilia on peripheral smear

13. Onchcerciasis- Biology
●Onchocerca volvulus - Causative Agent
●TISSUE dwelling parasite- filarial
nematode
●Family Onchocercidae

14. Onchcerciasis- Epidemiology
●Equatorial Africa
●Elevated regions of Mexico &
Guatemala
●Smaller foci in Saudi Arabia, Yemen,
Brazil, Ecuador, and Venezuela

15. Onchcerciasis- Pathology
●Adult worms reside in subcutaneous
tissues
●Often enclosed in fibrous nodules
●Microfilariae, which in this species lack
an enveloping sheath
●Released from female adults
●Localize in skin & subcutaneous tissues

16. Clinical Features I
●Skin is frequently involved
●Pruritus most common clinical
manifestation
●Wrinkling and skin atrophy

17. Clinical Features II
●Hypopigmentation or hyperpigmentation
●Papulovesicular lesions & localized
areas of eczematoid dermatitis
●Firm, nontender subcutaneous nodules
(over boney prominences)

18. Clinical Findings III
●Blindness most feared complication
●1.5K per 100K (endemic region) vs .25K
per 100K (base risk)
●Some areas 10% adult population blinded
●Conjunctivitis with photophobia
●Common and earliest finding

19. Clinical Findings IV
●Punctate keratitis (10-15%)
(accumulation of inflammatory cells
around dying microfilariae) usually no
sequlae
●Sclerosing keratitis (5%) and
chorioretinal lesions (5%) cause
blindness
●Anterior uveitis, iridocyclitis (5%) & less
frequently, optic nerve lesions (2%)

20. Vector
●Simulium species (blackflies)
●Simulium damnosum (major African
vector)
●No reservior host
●Estimated 30 million infected in Africa

21. Laboratory Diagnosis I
●Small piece superficial skin by excision
or punch biopsy weighed
●Incubated several hours in saline or
tissue culture media
●Microfilariae exit skin & counted in fluid
●�100 microfilariae/mg skin = heavy
infection

22. Laboratory Diagnosis II
●50 mg provocative dose
diethylcarbamazine
●Subsequent onset of symptoms, pruritus,
rash, fever, and conjunctivitis= Mazzotti
reaction
●Eosinophilia often prominent

23. Treatment
●Ivermectin, orally single dose 150 mg/kg
●This dose repeated q 6 to 12 mo’s
●Nodulectomy for large nodules (remove
the adult worms)

24. Case #2
●34 y/o Pakastanian male
●3d hx/o rigors, drenching sweats, & fever
●Croatia X14d’s
●Punjab Province

25. Physical Examination
●T 102.7° F
●Ill but nontoxic
●No specific findings on P.E.
●(-) spleenomegaly

26. Geo-epidemiology Pakastan
●Prevelance highest in Northwest Frontier
Province (6.5 % vs 3% baseline)
●Plasmodium falciparum increasing (54%
countrywide)
○33 % Punjab Province
○77% Sindh & Baluchistan Provinces

27. Transmission/Vector Ecology
●An. culicifacies
○Indoor feeder, breeds rice fields, channels, &
edges rivers/streams
●An. stephensi
○Indoor feeder, breeds polluted, fresh, and
brackish water

28. Transmission/Vector Ecology
●An. superpictus
○primarily outdoor feeder, breeds in rocky
streams and rivers
●An. sergenti
○Outdoor feeder, breeds in ditches, marshes,
ponds, & wells

29. Malaria- Worldwide
●60 million cases per annum
●Malaria increasing throughout tropics,
esp Indian subcontinent

30. Malaria- USA
●1988, 1,023 cases US malaria reported
●43 % were Plasmodium vivax
●46 % P. falciparum
●Three % P. malariae
●Two % P. ovale

31. Malaria- USA
●32/1,023 cases acquired outside US
●Six fatalities

32. Malaria- USA
●Malaria acquired by mosquito incrsing
●14 cases occurred USA 1950-1985
●Epidemiologic surveys California - 27
cases in 1987
●30 cases in 1988
●Eight cases in 1989
●All caused by P. vivax

33. Malaria - Life Cycle
●Incubation Period 12 to 14 days
●Sporozoites enter via bite of infected
female anopheline mosquito
●Parasites carried to the liver, where they
multiply inside parenchymal cells
○Preerythrocytic tissue phase

34. Malaria - Life Cycle
●Progeny released from ruptured
hepatocytes => RBC’s
●Inside RBC
●Progency degrade protein fraction of
hemoglobin

35. Malaria - Life Cycle
●Undergo asexual maturation from
trophozoite to merozoite
○Process known as schizogony
●Cycles of intracorpuscular multiplication,
rupture, and reinvasion responsible for
paroxysms of chills & fever

36. Malaria - Life Cycle
●Some parasites differentiate into
macrogametocytes or
microgametocytes, the sexual forms
●These infect mosquitoes that feed on the
victim

37. Malaria - Life Cycle
●In the gut of the mosquito, the definitive
host
○fertilization
○zygote formation
○production of new sporozoites take place

38. Clinical Features
●Malaise & Myalgias
●Headache
●Chills (with or without rigor)

39. Clinical Features
●Temperature to 41.5° C (106.7° F)
●Profuse sweating & Prostration may
appear
●Mild jaundice, hepatosplenomegaly, and
anemia often develop

40. Fever Patterns
●P. vivax & P. ovale infections cause QOD
(tertian) febrile paroxysms
○After maturation cycles synchronize
○Usually at end of first week
●P. malariae infection marked by
paroxysms Q3D (quartan periodicity)

41. P. falciparum
●Has capacity to obstruct microcirculation
in various organs
●Fever continuous or intermittent
●Cerebral involvement may lead to
delirium, focal disorders (e.g., seizures),
& coma

42. P. falciparum
●Splanchnic involvement may cause
protracted nausea, vomiting, diarrhea,
melena, & abdominal pain
●GI syndrome can be mistaken as
traveler's diarrhea
●Since there may be little or no fever

43. P. falciparum
●Lung involvement may cause pneumonia
& ARDS
●Hypoglycemia may be severe
●Rare syndrome of blackwater fever
○Massive intravascular hemolysis
○=> hemoglobinuria and ARF

44. P. malariae
●Can persist as an asymptomatic infection
for years or decades
●Usually responsible for late relapses
●This species likely to be cause of malaria
induced by transfusion

45. Laboratory Diagnosis
●Parasites in properly stained smears
peripheral blood
●Smears taken repeatedly for several
days because cyclic nature parasitemia
●Morphologic features of parasites (and
the infected host erythrocytes) useful in
species ID

46. Laboratory Diagnosis
●Indirect fluorescent antibody test- CDC
●Blood smear used to establish a Dx
●Serologic test useful in ID infected
donors in cases of transfusion malaria
●DNA probe being developed Dx P.
falciparum infection

47. Drug Resistance
●Chloroquine-resistant strains in all
countries with P. falciparum malaria
except
○Haiti & the Dominican Republic
○Central America west of the Panama Canal
○Middle East & Egypt

48. Chloriquine Resistant Malaria

49. Drug Resistance
●Resistance to
pyrimethamine-sulfadoxine (Fansidar)
widespread
○Thailand, Burma, Cambodia, and the
Amazon River basin
○Has been reported in sub-Saharan Africa
●Mefloquine-resistant strains- P.
falciparum identified Thailand

50. PO Treatment
●1,250 mg of mefloquine in a single dose
●Mefloquine is a schizonticidal agent
structurally related to quinine
●Primaquine 15mg po qd X 2wks
●If G-6-PD deficient than 45 mg po 1X/wk
X 8wks

51. IV Therapy-Indications
●Intolerant oral therapy
●Neurologic symptoms
●Peripheral asexual parasitemia > 5%
RBC’s infected

52. IV Therapy-Regimen
●Life-threatening P. falciparum malaria
●Intravenous quinidine gluconate
○Loading dose 10 mg/kg (maximum 600 mg)
NS infused over 1 to 2 hrs
○Then continuous infusion of 0.02 mg/kg/min

53. IV Therapy-Cautions
●Slow infusion rate
○Plasma quinidine levels > 6 mg/ml
○QT interval greater than 0.6 second
○QRS widening beyond 25 percent of
baseline
●Hypoglycemia, may be exacerbated
●Parenteral therapy until parasitemia <1%

54. Transitions to PO Therapy
●In most cases, PO Rx can be substituted
within 48 - 72 hrs
●Oral therapy, usually with quinine,
continued for 3-7 d’s
●Add additional agent (e.g., TCN 250 mg
p.o. Q6h X 7 d’s)

55. Case #3
●27 y/o CzekBat infantryman
●5 d hx/o high fever, rigors, malaise
●Severe Lumbar Pain and marked N/V
●Transfered for Renal Failure

56. Exam
●Subconjunctival Hemmorhage
●Petechial rash of Palate
●Marked Dermatographism

57. Laboratory
●WBC 20 K
●Platlets 105 K
●pH 7.32, pCO2 24, pO2 104 (RA)
●BUN 60, Creat 6.4
●K+ 3.7 meq/dl

58. Hemodynamics
●RA 4 torr
●PA 24/12 torr (mean 18)
●PAOP 12 torr
●MAP 90 (HR 74)
●RADIAL ARTERIAL Sat 95.4%, Mixed
Venous O2 Sat 84%
●C.O./C.I. 12.4 L/min/5.8 L/min

59. History I
●1950s United Nations troops in Korea
epidemic- serious febrile illness
associated with hemorrhages, capillary
leak phenomena, and renal failure
●Korean epidemic hemorrhagic fever

60. History II
●1913 eastern Russia, various regions of
Russia and China, including Siberia and
Manchuria, Korea and Japan
●1982 and 1983 same illness reported in
various parts of France
●A milder form - nephropathia epidemica
in Scandinavia - 1935

61. Biology
●Genus Hantavirus at least 4 species
●Hantaan virus (Korean hemorrhagic
fever)
●Seoul virus (milder form of Korean
hemorrhagic fever)
●Puumala virus (nephropathia
epidemica)
●Prospect Hill virus (isolated meadow
voles Maryland no disease)

62. Biology
●Family Bunyaviridae Genus Hantavirus
●3 molecules per virion
●Nonmessenger ss-RNA genome
●Spherical 80-115 nm Diameter
●Helical Capsid symmetry
●Lipo- and glycoprotein Envelope

63. Serology
●Viremia not usuallly noted at
presentation
●IgM & IgG antibodies usually present at
clinical presentation
●Immunfluorescent antibody test available
●Antigen-antibody complexes in serum
may be cause of tubular nephropathy
characteristic of illness

64. Epidemiology I
●Hantaviruses isolated rodents world-wide
●42% of Norway rats- Baltimore (1980
and 19860 (+) antibodies Hantaan virus
●Increased number naturally acquired and
lab- associated infections in Europe
●Recent outbreak in Belgium lab rats

65. Epidemiology II
●Virus in urine, feces, and saliva various
rodents, including field and laboratory
mice, rats, and voles
●Transmission rodent to rodent respiratory
●Human transmission inhalation infectious
aerosols rodent excreta
●No evidence human-to-human
transmission

66. Clinical
●5 Stages
●febrile
●hypotensive
●oliguric
●diuretic
●convalescent

67. Clinical
●Incubation period is 7 to 36 days
●Usually 10 to 25 days
●Severity of illness varies considerably
●Approx 65% of cases mild
●10 to 15% severe

68. Febrile
●Onset abrupt : chills, fever, backache,
abdominal pain, myalgia
●Fever peaks- 3rd or 4th day
●Relative bradycardia
●Severe illness, confusion, meningismus,
and convulsions occur
●Mortality with severe disease
approximately 40 percent

69. Febrile (dermatological
findings)
●Typical early findings diffuse reddening
of the face (sunburn)
●Dermatographism > 90% of patients
●Petechiae 3rd to 5th day, initially on
palate, pressure areas (axillary folds)
●Conjunctival hemorrhages

70. Hypotensive
●5th day, shock or hypotension may
occur (hypotensive phase)
●Mild cases, fall in BP is only transient
●Hct increases and marked proteinuria,
leukocytosis, and thrombocytopenia
develop.

71. Oliguric
●About 8th day
●BP returns to normal
●Oliguria develops
●BUN levels increase rapidly
●Hemorrhagic manifestations more
prominent

72. Diuresis
●About the 11th day
●CNS and pulmonary complications may
be seen
●Convalescent phase lasts 3 to 6 wk.

73. Prognosis
●Most patients survive the period of
oliguria
●Total illness of two to three weeks'
duration
●No specific therapy (??????)
●Overall mortality - five to 30 percent
●Residual renal dysfunction uncommon in
Korea may be more common in Europe

74. NE
●Nephropathia epidemica milder illness
●Seen in Scandinavia
●Sudden onset of high fever, headache,
backache, and abdominal pain
●On 3rd or 4th day, conjunctival
hemorrhages, palatine petechiae, and a
truncal petechial rash appear

75. NE
●Approx 20% of patients develop a toxic
condition become mentally obtunded
●Oliguria and azotemia develop
concomitantly with the hemorrhagic
manifestations
●Urinalysis reveals proteinuria,
hematuria, and pyuria
●Rash subsides in about 3 days
●Develops polyuria recovers weeks

76. Controlled Clinical Trial
●In China, 242 patients who had
serologically confirmed hemorrhagic
fever with renal syndrome
●Patients who had received intravenous
ribavirin - marked reduction in mortality
●Marked reduction in the risk of oliguria
and of hemorrhage

77. Theraputic Regimen
●Intravenous ribavirin- loading dose of 33
mg/kg
●Loading dose was followed by 16 mg/kg
every six hours for four days and by 8
mg/kg every eight hours for three days

78. Case #4
●25 y/o African male
●Intermittant gross hematuria X 8 mo’s
●Dysuria and Increased Frequency
●Infantryman in Croatia since June 1994
●4 yrs ago treated for something similiar

79. HX
●Somali tribe of kenya (nomadic)
●Garrisa District (NorthEastern Province) of
Kenya
●Traveled widely in search of bride
●Had Swum in Tana River in past 4 yrs
approximately 15 times

80. Laboratory
●U/A (+) RBC’s, (-) WBC’s, (-) nitrites, (-)
leukocyte esterase
●U/A had single egg discovered in
multiple slides of centrifuged urine
●However, diagnositic specimen
●Schistosomasis hematobium

81. Introduction
●Chronic trematode (fluke) infection of
humans
●Major worldwide health problem
●Three major species Schistosoma
mansoni, S. japonicum, and S.
haematobium

82. Geographic Distribution
●S. mansoni - Africa, Arabia, South
America, and parts of the Caribbean
●S. japonicum - Japan, China, and the
Philippines
●S. haematobium - Africa and the Middle
East
●A minor species, S. mekongi - mainland
Indochina

83. Biology/Life Cycle

84. Epidemiology I
●Highly endemic, 2-3 million people
●Infection rates by region as high as 60%
●Risk elevated in rainy seasons March to
May and Late September to November

85. Epidemiology II
●Haematobium coastal plain and lower
Tana River Valley
●Taveta vicinity (extreme southwestern
Coast Province)
●Kitui District (Eastern Province)
●Nyanza Province (bordering Lake
Victoria)

86. Epidemiology III
●Intestinal Shistosomasis less widely
distributed
●Kitui and Machakos Districts (Eastern
Province)
●Taveta vicinity
●Bordering Lake Victoria
●Rusinga and Mfango Islands (Lake
Victoria)

87. Epidemiology
Garissa
District
Tana
Rive
r
Coast
Provinc
e
Kitui
Distric
t

88. Epidemiology

89. Clinical Features I
●Three stages of disease may occur
●First stage, schistosomal dermatitis
●Develops acutely within a day of
cercarial penetration of the skin
●Swimmer's itch, similar reaction in US
●26 percent of Michigan residents have
antischistosomal antibodies

90. Clinical Features II
●Second stage of disease
●Acute schistosomiasis, or Katayama
fever
●Four to eight weeks after heavy,
primary, infection
●Fever, cough, hepatosplenomegaly,
malaise, myalgias, urticaria, and
eosinophilia

91. Clinical Findings III
●Stage III - Chronic schistosomiasis
●Caused by heavy deposition of eggs in
intestine or bladder and in the liver
●S. haematobium infection, principal
symptoms -terminal hematuria, dysuria,
and frequency
●Hydronephrosis and pyelonephritis may
develop 2ndary fibrosis and infection

92. Non-Haematobium infection I
●S. mansoni, S. mekongi, or S.
japonicum infection
●Fever, malaise, abdominal pain,
diarrhea, or hepatosplenomegaly
●Presinusoidal hepatic trapping of eggs
●Granulomatous reaction induces portal
hypertension collateral esophageal
varices

93. Non-Haematobium infection II
●Eggs may be shunted from liver to lung,
with PAH
●Death 2ndary variceal bleeding
●Hepatic encephalopathy rare- hepatic
parenchyma spared
●Less common sequelae - intestinal
polyps, bladder carcinoma, persistent
Salmonella infections

94. Non-Haematobium infection III
●Infrequently, focal neurologic dysfunction
2ndary aberrant localization in CNS tissue
●Embolic deposition of S. japonicum eggs
may produce cerebral granulomas
●S. mansoni may lead to transverse
myelitis involving the midthoracic or
lumbar spinal cord

95. Diagnosis I
●Suggested - history of possible exposure
●Exposure may be years distant
●Compatable gastrointestinal or urinary
tract symptoms, hepatosplenomegaly,
eosinophilia, or combination of findings
●Serologic tests are rarely helpful

96. Diagnosis II
●Document presence of active infection
●=> find viable eggs
●Assess intensity of infection -quantitate
egg excretion

97. Diagnosis III
●Stool examination should include search
for all Schistosoma species
●S. haematobium, urine should be
obtained between 10:00 A.M. and 2:00
P.M.
●Microscopic examination of biopsy
specimens of rectal mucosa

98. Schistosoma haematobium

99. Treatment
●Praziquantel is drug of choice
●S. haematobium, single dose 40 mg/kg po
●S. japonicum, S. mansoni, and S. mekongi,
20 mg/kg po TID X 1 day
●Drug efficacious, paucity of side effects, is
convenient

100. Case #V
●45 y/o Bengladeshi Male
●Fever X 4-5 wks with wasting illness

101. PE
●No spleenomegaly
●No hepatomegaly

102. Laboratory
●Anemia
●Thrombocytopenia
●Leukopenia

103. Etiology and Epidemiology
●L. donovani species complex includes
several species
○e.g., L. infantum, L. donovani, and L.
chagasi
●Endemic in areas of India, China, Central
and South America, East and West
Africa, and the countries surrounding the
Mediterranean

104. Etiology and Epidemiology
●Sandflies of genus Phlebotomus are the
insect vectors
●In India, no extrahuman reservoirs
known
●Other regions, several mammals,
including dogs, foxes, & wild rodents
reservoir hosts

105. Patient Specific Epidemiology
●Visceral leishmaniasis rural disease is
endemic countrywide
●Kala-azar outbreak affected widespread
areas of the Seraganj District, central
Bangladesh
●Late June, 1989, at least 1,000 cases
were reported

106. Patient Specific Epidemiology
●Outbreak probably related to earlier one
adjacent Pabna District
●Other risk areas: Shrifalgati, Nandiganti,
Newargacha, Dugli and Makarkole
districts

107. Croatian Epidemiology
●Foci of visceral leishmaniasis (VL) are
distributed countrywide
●Elevated risk in southeastern Serbia in
the area of Dobric
●Along the Dalmatian Coast
●Historically, active foci:Macedonia,
Dalmatia, the island of Mljet (Croatia),
and Montenegro

108. Pathogenesis
●Flagellated promastigotes L. donovani
introduced insect bite
●Enters macrophages of RES, morph =>
amastigotes
●Multiply in phagocytic cells

109. Pathogenesis
●Amastigotes disseminate
hematogenously
●Invade reticuloendothelial cells spleen,
liver, lymph nodes, bone marrow, and
skin

110. Clinical Features
●Symptoms gradual onset several months
after infection
●Weakness, dizziness, weight loss,
diarrhea, & constipation
●Fever, almost always develops, may
spike twice daily & is sometimes
acompanied by rigors

111. Clinical Features
●Liver & spleen enlarge
●Spleen often expands into iliac fossa
●Anemia & leukopenia

112. Clinical Features
●Thrombocytopenic pxt => gingivae,
nose, or GI tract bleeding,
●Cutaneous ecchymoses and petechiae
●Death 2ndary bacterial infections, severe
anemia, or uncontrolled bleeding

113. Laboratory Findings
●Anemia, leukopenia, thrombocytopenia
●Hyperglobulinemia &hypoalbuminemia
●(+) fever, hepatosplenomegaly, and
exposure endemic areas
●Definitive diagnosis organism in host
tissues cultured Novy-MacNeal-Nicolle
(NNN) medium

114. Laboratory Findings
●Leishman-Donovan bodies (amastigotes)
stained tissue samples
●Dx established by bone marrow
aspirates
●Splenic aspirates have highest yields -
risky
●Liver biopsy or aspiration lymph nodes
also diagnostic

115. Therapy
●Sodium stibogluconate (pentavalent
antimony) Rx of choice
○Pentostam - CDC Drug Service/Atlanta
(404-639-3670, days; 404-639-2888, nights
and weekends)
●If initial Rx fails, amphotericin B or
pentamidine used

116. Therapy
●Amphotericin B uniformly effective in
Indian comparative series
●May respond sodium stibogluconate +
recombinant human interferon gamma
●Or liposomal amphotericin B or
ketoconazole

117. Meissner 6 W’s- ID Hx/o
●WHERE & WHEN? (travel history)
●You did WHAT WITH WHO, WHERE ?!!!!!!!!
(sexual history)
●WACKY WAYS to WASTE time?
(avocational/occupational history)
●WEIRD and non-WEIRD WILDLIFE?
(Zoonoses)
●Wolfing WHAT? (food and ingestion history)
●WEAK-knead WIMP

118. Case #6
●45 y/o Polish Internist
●Chest pain
●Increasingly disruptive behavior in his
unit
●Obtained EKG on all patients that he
saw
●Disrupted sleep & Grandiose Thought

119. UN Peacekeeper Stressors

120. Interactions- Stressors vs
Anti-Stressors
●Magnitude
●Combination of stressors
●Quality of leadership and comradeship
●Level of preparation and training
●Variability within units

121. Duration of Deployment
●Pre-planned vs open-ended duration
●Increased stress with long deployments
●Predictibility is the highest GOOD!

122. Definition of Mission
●Clear vs ambigous or shifting
●Passive vs active
●Glamorous vs unglamorous
●Clear signs of progress vs no clear
progress

123. Living Conditions
●Comfortable vs spartan
○Sleep discipline
○Position improvement projects
○Programed improvments in facilities
●Universal vs unequal hardship
○Equalize conditions if possible
○‘Gripping’ is adaptive
○Maintain fairness

124. Degree of Contact
Home, Family, Culture
●Telephone availability
●Telephone limitations
●Unauthorized casualty reporting
●Mail turn around time
●Comfort items
●Vistors from HOME!

125. Acculturation
●Similiar vs dissimiliar
●Degree of immersion
●Extreme immersion
●‘When in Rome’ can lead to Orgies!
●Prevent
○cultural/racial slurs/slang
○cultural stereotyping

126. Heaven & Hell!
●Heaven: The British are the policemen,
the French are the Chefs, the Italians
are the lovers, the Germans are the
mechanics, the Swiss run the railroads.
●Hell: The Germans are the policemen,
the Swiss are the lovers, the Italians run
the railroads, the French are the
mechanics, and the British are the
Chefs!

127. Promote Cultural
Understanding
●Pre-deployment briefings of cultural &
historical issues
●Teach common key phrases in language
●Cultural briefings
●Show host nation in best light

128. Immunize against culture
shock
●TRY TO UNDERSTAND customs,
habits, ways of thinking
●Respect those customs and habits
●If unable to respect, SUPRESS
disapproval
●Adopt foreign manners and habits

129. Immunize against culture
shock
●Suppress your personal peculiarities
●MIND YOUR OWN BUSINESS
●Be Friendly
●Accept people as they are!
●Try to see the situation from their side!

130. Suffering, Horror, and/or
Death of Others
●Discuss risks before and during
deployment
●Look at pictures and videotapes of
previous atrocities to acclimate
●WORK through your feelings: emotional
debriefing

131. Personal Injury and Death
●Mines
●Snipers
●Ambush
●Harrassing arterillary or rocket attacks
●Frustrating Rules of Engagement

132. UNMO Stresses
●Two man teams - different cultures
●Passive role in the face of atrocities
(Report the news, don’t make it!!)
●Stringent limits on use of deadly force
●Living in the moral ‘battlefield’
●The Warrior ° The Healer