Chapter 17HEALTHCARE AND THE CHEMICAL SURETY MISSIONROBERT GUM, D.O., M.P.H.* * Lieutenant Colonel, Medical Corps, U.S. Army; Combat Casualty Care Office, U.S. Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland 21010-5425 |
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Medical officers with assignments to U.S. Army depots or other installations storing chemical warfare agents face a number of unique challenges. Not only will newly assigned general medical officers provide patient care to both military and civilian workers, they will also have a myriad of additional duties unique to chemical weapons storage sites. The depot may be physically isolated and a considerable distance away from the Medical Center (MEDCEN) or Medical Department Activity (MEDDAC) responsible for providing medical support and consultation. The preventive/occupational medicine physicians are usually responsible for providing this support and are a source of information and guidance. Other governmental agencies have also been identified to assist medical personnel in acquiring solutions to unfamiliar medical problems related to chemical exposure (Exhibit 17-1).
Physicians assigned to installations with a chemical surety mission (the term encompasses safety, security, and reliability) must be able to recognize and treat a wide variety of chemically related diseases and injuries. Time or assets are seldom available, however, to train a general medical officer in the unique occupational setting of depot operations. At the present time, newly assigned general medical officers are required to complete the Medical Management of Chemical Casualties Course given at Aberdeen Proving Ground, Maryland. This course provides the basic concepts needed to recognize the clinical signs and symptoms of a chemical agent exposure and the appropriate therapeutic interventions used in treating and managing chemical agent casualties. In addition, the Office of The Surgeon General sponsors the Toxic Chemical Training for Medical Support Personnel Course, which is conducted at the Chemical Demilitarization Training Facility at the Edgewood Area of Aberdeen Proving Ground. This training course has incorporated presentations on medical diagnosis and treatment that are essential to managing the health-related concerns of the chemical surety mission. These orientation courses provide essential information to the medical officer beginning his atypical assignment. As used in this chapter, a chemical agent is defined as a chemical substance intended for use in military operations to kill, seriously injure, or incapacitate a person through its physiological effects. Riot control agents, chemical herbicides, smoke, and flame are not officially defined as chemical agents. Although the chemical agents discussed are unique to the military, the hazards to the workers are common to many industries. Examples include pesticide workers who are exposed to acetylcholinesterase inhibitors (the operative mechanism of nerve agents) and carbonyl chloride (phosgene), which is used in the production of foams and plastics. Both are transported daily on the nation’s highways. In addition to these chemical threats, many physical hazards found in the chemical storage depot are shared by other types of operations. The operation of forklifts, the presence of excessive noise, heat stress, lifting, and other chemical exposures (in addition to chemical warfare agents) are only a few of the more common hazards. The intended use, packaging, and storage of chemical munitions, however, present different hazards and therefore require different controls. The system of controls, procedures, and actions that contribute to the safety, security, and reliability of chemical agents and their associated weapon systems throughout their life cycle without degrading operational performance is known as chemical surety. An integral part of a physician’s practice is addressing the occupational healthcare needs of the patients. This responsibility includes identification of occupational and environmental health risks, treatment of disease and injury, and patient counseling concerning preventive behavior. This task by itself is time-consuming and presents demands that, in part, can be performed by the occupational health nurse, the industrial hygienist, and other clinic staff members. Although industrial hygienists are often not assigned to the health clinic, they are an integral part of the healthcare team. The industrial hygienist maintains a hazard inventory that contains conventional hazards as well as a list of chemical agents located at the installation. He routinely designs primary prevention strategies and frequently oversees hearing conservation, respiratory protection, and occupational vision programs. The information he provides is necessary to evaluate the work environment and to determine the appropriate frequency of periodic medical examinations. Close and frequent coordination with this individual is imperative for developing a knowledge of the worksite and the subsequent development of a medical surveillance program. Just as it is imperative to work closely with industrial hygiene and safety personnel, medical personnel must also work in accord with the command, supervisors, personnel officers, and the workers. Maintaining these relationships is frequently difficult, but by identifying and addressing concerns of both the management and the individual workers, medical personnel can establish a basis for formulating appropriate preventive medical measures. |
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The Chemical Personnel Reliability Program (CPRP) is a management tool used within the army to identify chemical surety duty positions and to manage the persons assigned to these positions. It also provides a way to assess the reliability and acceptability of personnel being considered for and assigned to chemical duty positions. Chemical surety material is defined in Army Regulation 50-6, Chemical Surety, as “chemical agents and their associated weapon system, or storage and shipping containers, that are either adopted or being considered for military use.”1(p43) The program was established to ensure that the personnel assigned to positions involving access to or responsibility for the security of chemical surety material are emotionally stable, loyal to the United States, trustworthy, and physically fit to perform assigned duties. The certifying official is the commander’s representative for the CPRP and ultimately responsible for its administration. The decision to qualify or disqualify personnel for CPRP duties is made by the certifying official, with input from the personnel officer and medical personnel. The certifying official must also determine the appropriate medical surveillance category for each worker (see below for a discussion of the four categories) based on the worker’s potential for exposure. The CPRP requires both preassignment screening and continuing evaluation. This screening and evaluation is performed when an individual is assigned initial CPRP duties, when a new assignment is being considered by the certifying official, and once every 5 years thereafter. The CPRP screening/evaluation consists of an initial interview with the certifying official, personnel records screen, medical evaluation, and a final evaluation and briefing by the certifying official. During each portion of the screening process, evaluators look for any evidence of potentially disqualifying factors that may affect personnel reliability or suitability for CPRP duties. The potential disqualifying factors of medical relevance include: alcohol abuse, drug abuse, inability to wear protective clothing and equipment required by the assigned position, or any significant physical or mental condition that in the judgment of the certifying official may be prejudicial to the reliable performance of CPRP duties. Factors that restrict the wearing of protective clothing include: (a) the inability to obtain a seal with the protective mask, (b) an allergy to protective clothing and equipment, (c) any medical condition that precludes correct wear and use of protective clothing, and (d) poor visual acuity that requires the use of glasses unless mask optical inserts are used. Contact lenses are not permitted to be worn with the protective mask because they can concentrate agent beneath the lens, or, more commonly, a foreign body will become lodged beneath a contact lens, necessitating immediate removal. This cannot be done in a chemical environment! Any medical conditions, including the use of any prescribed medications, that may detract from an individual’s ability to perform assigned chemical surety duties must be communicated to the certifying official by oral notification and confirmed in writing. In addition, the physician must provide a recommendation as to the suitability of the worker to continue CPRP duties. Documentation of these communications should be included on the Standard Form 600. As in all healthcare, documentation is extremely important and, in this case, subject to examination during a Chemical Surety Inspection (CSI). Exhibit 17-2 lists the administrative documentation necessary to support a CSI. |
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Follow-up evaluations may be warranted during the acclimatization period for selected workers. The phenomenon of heat acclimatization is well established, but for an individual worker, it can be documented only by demonstrating that after completion of an acclimatization regimen, the worker can work without excessive physiological heat strain in an environment that an unacclimatized worker could not withstand. The IMA needs to be intimately involved in developing the acclimatization program for the installation. Annual or periodic examinations should monitor individuals for changes in health that might affect heat tolerance and for evidence suggesting failure to maintain a safe working environment. Education of the workers and supervisors, however, is the single most important preventive measure in avoiding heat casualties. Personnel required to wear toxic-agent protective clothing are also at high risk for dehydration, which is a contributing factor for developing heat injury. The thirst mechanism is not adequate to stimulate a worker to consume as much as a liter of water per hour that may be lost in sweat. If weight loss exceeds 1.5% to 2.0% of body weight, heart rate and body temperature increase, and work capacity (physical and psychological) decreases.7 Workers should be required to consume at least 8 oz of cool water at each break period; for moderate work in greater than 80°F wet bulb globe temperature (WBGT), the average male should plan on 1 qt of fluid per hour; more water may be required depending on the ambient temperature and humidity. The average diet in the United States provides adequate salt intake for the acclimatized worker. The unacclimatized worker may excrete large amounts of salt: another reason that he will need close monitoring while adjusting to the evaluated temperatures and decreased evaporative cooling. Individuals on medications that further deplete sodium (ie, diuretics) will need even closer monitoring and medical follow-up. The judicious use of sodium replacement may be required during the acclimatization period. |
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All personnel entering an area where chemical munitions are stored must recognize and understand the potential hazards to their health and safety associated with chemical agents. Workers must be required to recognize signs and symptoms of exposure to these agents. They must be totally familiar with the procedures to assist a coworker and to summon assistance in the event of an accident. Visitors must be briefed on basic procedures that will permit them to complete their visit safely. Visitors must also be evaluated to ensure they can wear a mask appropriately should escape become necessary. The objectives of training programs for chemical workers are to provide awareness of the potential hazards they may encounter and to provide the knowledge and skills necessary to perform the work with minimal risk. Additional requirements are to make workers aware of the purpose and limitations of safety equipment and to ensure that they can safely avoid or escape during an emergency situation. Although the IMA may be requested to present a discussion of medical topics, he is responsible for reviewing the training program’s lesson plans and the SOPs to ensure the correctness and comprehensiveness of the medical aspects. The level of training should be commensurate with the workers’ job function and responsibilities, which will necessitate a modification of training material and techniques to accommodate the audience. The training programs should consist of both classroom didactic instruction and hands-on practice, when feasible. Although this chapter primarily addresses the principles of occupational medicine as they apply to working in a chemical environment, it should be recognized that other workplace hazards exist. Training programs may focus on chemical warfare agents, but they should also address any additional physical and chemical hazards. A number of these hazards may be obvious and directly related to the primary mission; for example, the heat stress associated with wearing chemical protective clothing. Additionally, certain occupational medical hazards are common to all industrial operations (eg, low-back strain), which may produce excessive absenteeism and disability. By working closely with management, medical officers can minimize the impact of these additional safety and industrial hazards. Special consideration should be given to training workers in the recognition of signs of exposure in a coworker wearing chemical agent protective clothing. Describing fasciculations and localized diaphoresis will be of limited value because the coworker will be wearing full protective clothing. Alerting the workers to watch for lack of coordination, inappropriate activity, and pinpoint pupils would be of far greater value. Moreover, discussions of the early symptomatology will give the workers the capability of recognizing chemical agent exposure early enough to permit evaluation prior to the onset of serious injury. These signs and symptoms are discussed at length in other chapters of this text. Each employee should be thoroughly familiar with the requirements for providing effective self-aid and buddy-aid. The first rule of protection—to protect oneself from injury—must be emphasized. There are numerous case reports of individuals or groups attempting to assist someone exposed to toxic compounds only themselves to become casualties. Workers will require training in proper lifts and carries, both with and without a litter. All workers should know the procedure for requesting medical assistance. Many installations have one “hotline” for medical, technical escort unit, and security support. Workers should be aware of any set format for reporting emergencies that will expedite the report and response time. Once assistance has arrived, the support personnel should be given accurate and complete information about the accident or incident. Teaching the worker a logical format in which to present this information is extremely helpful. Their reports should include the nature of the accident or incident (ie, the agent involved and number of casualties), what has been done for the victims to that point (eg, the number of MARK I injectors administered), and whether personnel are missing. Support personnel can ask for additional information as the situation progresses. Decontamination procedures must be well known to all chemical workers. The training class should present the M258 and M291 kits and their contents and make clear the use of household bleach in the decontamination process. Current doctrine specifies that in a tactical environment 0.5% bleach be used for skin decontamination. In depot operations, however, 5% bleach is used. This stronger concentration may be used because workers exposed at the depot will be decontaminated and then thoroughly rinsed in a fixed facility in a relatively short time. Soldiers in the field, however, may be decontaminated several times and not be rinsed thoroughly for several hours. Repeated applications of 5% bleach without a complete and thorough rinse will cause skin injury. The bleach used for decontamination should be stored in airtight containers and dated. Bleach deteriorates and may not be as effective after several months. Decontamination includes removal of contaminated clothing and the decontamination of skin using the bleach solution. Care must be used to avoid putting bleach in open wounds and the eyes. These areas must be rinsed with copious quantities of water. The bleach requires a contact time of approximately 15 minutes to be fully effective. Small areas can be decontaminated by removing the contaminated section of clothing and following the directions on the M258 or M291 kits. Medical evaluation, treatment, or both is always required. Several additional decontaminants are used at the depot. They are generally very caustic and are not to be used on the skin. They include super tropical bleach (STB), high-test hypochlorite (HTH), 10% sodium carbonate, and 10% sodium hypochlorite. Healthcare personnel must be aware what decontaminants are stocked and what they are used for in case they are used inappropriately and a worker develops a medical problem. The industrial hygienist should be able to furnish this information. Outergarments should never leave the installation, even for laundering. If the clothing is contaminated, it will pose a chemical agent exposure hazard to the launderer. The use of disposable outer garments or decontamination prior to washing will generally solve this problem; however, a change in contractor or new personnel involved in the transportation or laundering process must be addressed. |
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Clinics located at depots with a chemical surety mission should have an area designated for the decontamination of exposed patients. Generally the treatment area for these patients is separate from the normal patient treatment areas. These facilities are rarely used for an actual chemically contaminated patient, however. A conscious effort must be made to keep these rooms at 100% operational capability. To maintain this capability, the medical staff must develop standing operating procedures (SOPs) that are comprehensive and detailed. The planning phase is essential to a successful operation, but the plan is useless if the personnel involved are not totally familiar with their responsibilities. Planning is an ongoing process that must be kept current in an ever-changing world. If the planning and updating process stops, the resulting document loses its usefulness. Unfortunately, many SOPs are written, only to be placed in a file for months without being reviewed by assigned personnel, only a few of whom may have been involved in initially producing the document. A routinely scheduled review and update of the clinic’s SOPs not only keeps the document current but, more importantly, requires that the healthcare personnel think about the plan and refamiliarize themselves with the operating procedures. In addition to producing viable internal SOPs, external coordination dictates Memorandums of Agreement (MOAs) with local agencies. The nature of the chemical agents being stored or demilitarized requires that preparations be made for receiving and treating casualties beyond the capability of the installation clinic. While stabilization may be done at the clinic, hospitalization will require outside facilities. The specter of chemical casualties may make local hospitals needlessly reluctant to accept chemical casualties even after decontamination. Existing MOAs will make the transfer much smoother and will stimulate the local hospital to do preaccident planning and training themselves. Much of the coordination required for outside agreements will be handled through command channels. The medical officer and medical administrator can accomplish much, however, by interpersonal contact with the medical facilities and the emergency medical personnel who will respond to an installation emergency. Coordination and interaction between civilian and military medical resources should be a continuous process. The IMA must take the lead to ensure the limited post resources are adequately augmented by off-post medical facilities. Staffing and treatment capabilities of off-site emergency medical facilities should be verified to ensure appropriate resources are available. Training of civilian resources is coordinated through the Chemical Stockpile Emergency Preparedness Program (CSEPP); the Program Director for CSEPP is located at the Edgewood Area of Aberdeen Proving Ground, Maryland. Unfortunately, the many demands placed on the IMA limits the amount of time he can devote to coordinating with local healthcare providers and administrators. Communicating with local supporting agencies, however, will be extremely valuable should an incident occur. The physician assigned as the IMA should have attended the Toxic Agent Training Course and the Medical Management of Chemical Casualties Course prior to reporting for duty. Enlisted personnel and civilian healthcare providers will require training by the medical officer. Evacuation plans, coordination with off-post civilian medical facilities, MOAs, and periodic inventories (with restocking of supplies and equipment) are the responsibility of the IMA. As individual training continues, collective training in the form of drills should become a routine part of the clinic schedule. Only the successful completion of all of the above will ensure readiness for proper management of a chemically contaminated patient. Each installation with a chemical surety mission is required to develop detailed plans and procedures to be implemented by the emergency actions community in response to a Chemical (Surety Material) Accident or Incident (CAI). Health services support during Chemical Accident or Incident Response and Assistance (CAIRA) operations involves personnel with a wide range of medical expertise who will be involved in providing emergency care. A decontamination area must be a part of the early medical care to limit the degree of exposure to the casualty. Emergency medical care will, initially, be provided by nonmedical workers who are responsible for removing the casualties from the site of injury through a personnel decontamination station and to the waiting medical team. Further evacuation may be required for one or more victims, either to the Installation Medical Facility (IMF) or to an off-post medical treatment facility (MTF). Civilian medical facilities may be required to receive the injured personnel, and they also will need their own supplies, equipment, and training appropriate for treating these casualties. The fundamental pathophysiological threats to life (namely, airway compromise, breathing difficulties, and circulatory derangement [the ABCs]) are the same for chemical casualties as they are for casualties of any other type. Because these are chemical agent casualties, all personnel involved must be provided additional training. The IMA, whether military or civilian, must be very proactive in developing medical teams, medical training programs, and strong community relations. A list of chemical agents, the number of personnel involved, the location of the work area, a summary of work procedures, and the duration of the operation is necessary to develop appropriate emergency medical plans. This information is available through the installation commander or the certifying official. In addition, the most probable event (MPE) and maximum credible event (MCE) must be defined to determine the anticipated casualty loads in either situation. An MPE is the worst potential event likely to occur during routine handling, storage, maintenance, or demilitarization operations that results in the release of agent and exposure of personnel. An MCE is the worst single event that could reasonably occur at any time, with maximal release of agent from munitions, bulk container, or work process as a result of an accidental occurrence. The Office of The Surgeon General will develop guidance for use by installations in estimating the chemical agent casualties expected from an MPE or an MCE. For planning purposes, medical staffing requirements are based on the MPE for the installation. Because an MCE is expected to exceed the capabilities of the Installation Medical Facility, medical contingency plans and coordination with local, state, and federal emergency medical authorities is essential. The IMA is responsible for developing and periodically updating MOAs with local civilian hospitals and supporting military MTFs to augment the installation medical treatment capabilities. The IMA must actively participate in training both medical and nonmedical personnel. Nonmedical workers require training in self-aid and buddy-aid as a minimum. The Installation Response Force (IRF) is responsible for providing the immediate safety, security, rescue, and control at the chemical accident or incident site to save lives and reduce exposure to hazards. The IMA must approve the training program for both workers and the IRF and must review their lesson plans for accuracy and completeness. The essentials of this training include recognizing signs and symptoms of agent exposure, first aid, self-aid, buddy-aid, individual protection, personnel decontamination (including decontamination of a litter patient), and evacuation of casualties. Active participation in the training by the IMA will ensure that the personnel understand their role, and that the medical care given by people who are not healthcare professionals meets acceptable standards. Healthcare providers, as well as local officials, are concerned about the spread of contamination. The procedure for decontamination of litter patients can be found in Appendix E of U.S. Army Field Manual 8-10-4, Medical Platoon Leaders’ Handbook: Tactics, Techniques and Procedures.8 The IRF will decontaminate patients and pass them across a hotline to the Medical Response Team (MRT). At that point the casualty should be completely clean. Civilian officials may require a casualty “certified clean” before moving the patient off the military installation. This requirement may be avoided through adequate coordination and training prior to an exercise or an actual chemical accident or incident. Building confidence in the civilian sector through education and communication is essential in providing a rapid and adequate medical response. Chemical Accident or Incident Response and Assistance encompasses actions taken to save life and preserve health and safety. This support involves a continuum of medical care, ranging from self-aid/buddy-aid in the field to treatment at a tertiary care facility. Due to the nature of some chemical warfare agents, proper care and adequate decontamination must be provided early in the care to avoid serious injury or death. The levels of medical care include the following: |
MOAs are required with local MTFs, local emergency medical services, ambulance services, and regional or state emergency medical services officials. The MOAs and frequent coordination with these agencies are necessary to ensure that appropriate off-post resources will be available for support during a chemical accident or incident. Because of the unique nature of chemical agents, training, as defined in an MOA, must be provided to the supporting civilian agencies. A proactive stance in giving and sustaining education will enhance the relationship with the civilian community. Many civilian medical personnel and officials are very supportive and willing to play an active role in Chemical Accident or Incident Response and Assistance exercises. Assisting them in training and providing them with appropriate supplies and equipment will go far in enlisting their future support and allaying some of their fears of the unknown. The U.S has produced and stored a stockpile of chemical warfare agents since World War I. These projectiles, rockets, mines, and ton containers have been maintained at eight depots in eight states: Aberdeen Proving Ground, Maryland; Anniston Army Depot, Alabama; Blue Grass Army Depot, Kentucky; Newport Army Ammunition Plant, Indiana; Pine Bluff Arsenal, Arkansas; Pueblo Army Depot Activity, Colorado; Tooele Army Depot, Utah; and Umatilla Army Depot, Oregon. In addition, two additional states could possibly be affected should there be a large release of agents: Washington and Illinois. The majority of chemical agents are stored in bulk containers that do not have explosive components. Leaking chemical agents have not presented a health threat to areas surrounding these depots. However, continuing to store the aging munitions may present a risk of chemical agent exposure. The M55 rocket is the most hazardous of the chemical munitions. The rocket contains propellant and a stabilizer that could degrade and form reaction products that might cause ignition. In 1985, the U.S. Congress initiated a program to dispose of our entire stockpile of lethal chemical agents. There are multiple reasons for destroying these chemical warfare agents:
Incineration has been determined to be the process that will safely treat all components of the weapons. The destruction facilities were built with back-up systems to prevent environmental release of agent. The U.S. Public Health Service reviews plans and monitors operations of these chemical destruction plants. The appropriate state environmental authorities must issue permits prior to beginning the incineration process. Despite the extensive precautions in building the destruction plants, the U.S. Army and the Federal Emergency Management Agency (FEMA) are working with local emergency responders to enhance their capabilities. Training in the medical management of chemical agent casualties specific to the installation is provided frequently to first responders and emergency management officials through CSEPP. Critics of the army’s high-temperature incineration on Johnston Island have found the method to be very controversial and undesirable. The disagreement among scientific experts concerning the incineration process and the emotional concerns of populations surrounding the eight U.S. depots have created numerous debates over the chemical agent destruction program. This controversy has presented the army with numerous challenges in risk communication and preparation to complete the destruction mission. Extensive security and safety measures have been adopted to ensure that an accident or incident involving the chemical warfare agents and chemical surety material is avoided. The containers are typically stored in an igloo (ie, a storage building topped with 3–4 ft of earth and concrete) and transported in large overpack containers (ie, a container within a heavy container) designed to withstand an explosion. The agent is destroyed at 2,700°F. Metal parts are also incinerated. Exhaust gases are passed through extensive pollution-control systems. Munitions are destroyed in small quantities in thick-walled rooms that are designed to withstand detonation. The likelihood of an accident that results in exposure of surrounding off-post areas is extremely remote in day-to-day operations. The solid residue remaining from ash, fiberglass, and wooden dunnage are evaluated for contamination and are transported to approved landfills. Brine (a by-product waste) is packaged and also sent to approved landfills. There is no water discharge resulting from the incineration process. Stack effluent must meet all requirements of the Clean Air Act,10 especially the amendments that were passed in 1970,11 1977,12 and 199013; (these last three versions were codified in the United States Code in 199014). In addition to carbon dioxide and oxygen, small quantities of sulfur dioxide, oxides of nitrogen, carbon monoxide, and particulate are discharged. Special precautions have been taken to reduce and eliminate the formation of furans and dioxans from the incineration process. Discharges from the stack are continuously monitored to ensure that the requirements of the Clean Air Act are met. Even though the possibility of an event leading to the contamination of an area surrounding a community is remote, extensive planning and preparation have been accomplished. The U.S. Army and FEMA have jointly enhanced the emergency preparedness of these communities. The unique challenges of chemical warfare agents, aging munitions, and protecting worker health in a chemical environment can prove a rewarding experience for healthcare providers. The personnel reliability program places numerous safety and administrative demands that require that the physician acquire knowledge in occupational medicine that many physicians never experience. Unlike many clinicians, the IMA is thrust into an environment that requires interaction with multiple professional groups. Coordination with industrial hygienists and safety officers will result in an awareness of the workplace and the work conditions that is seldom appreciated by other physicians. Designing a medical surveillance program to prevent illness and injury is seldom attempted by most physicians in clinical practice. This secondary preventive measure will augment and reinforce the primary preventive efforts of safety and industrial hygiene measures. Appropriate surveillance requires a thorough knowledge of the chemical agents. Requisite information is available through mandatory courses and on-the-job training. The chemical demilitarization process places additional demands on U.S. Army Medical Department personnel. In addition to the many responsibilities inherent to the chemical surety mission, the IMA may be challenged with risk communication. Many of the civilians living near depot storage facilities do not approve of the plan to incinerate the 30,000 tons of agents stored at these sites. Healthcare providers can play an important role in providing information and building confidence in the U.S. Army’s ability to safely destroy these agents through incineration. |