Historical Look Back: Discerning the Need

The JICSTC was first created to fulfill what was seen as a training shortfall that, left unresolved, would hinder the ability to meet an emerging DoD medical mission priority. There was no 1 driver that pointed to the need for a solution; rather the JICSTC concept was born out of the convergence of several factors that evolved over a period of several years.

In 1999, an ad hoc workgroup operating within other forums in the Pentagon began to informally assess the emerging Homeland Security and Military Assistance to Civil Authorities (since renamed Defense Support to Civil Authorities) mission, and particularly the role of the RCs in mounting a widespread medical response. It was reasoned that any response to a significantly large event within the boundaries of the United States, particularly one involving weapons of mass destruction (WMDs), would draw upon the technical acumen of National Guard and Reserve members who, when not on military duty, are in effect dispersed throughout the nation.^{Footnote ‡} This ad hoc group included representation from across the DoD and from other governmental offices, shown in Table 2.

TABLE 2 JICSTC Ad Hoc Workgroup Participation

Spanning several years, this evaluation included examination of the geographic distribution of DoD medical assets, review of the capabilities of the National Disaster Medical System (NDMS), an informal assessment of the state of preparedness within the broader DoD medical community, and analysis of the relevant training, existing doctrine, and the available plans and guidance.

This effort benefited from several contemporary activities that sought to evaluate readiness posture both regionally and on a national level, including the Top Officials (TOPOFF) exercises. These additional inputs pointed to the emerging role of DoD as a potential responder within the realm of the (then) Federal Response Plan (FRP) and Emergency Support Function (ESF) 8-Medical. Moreover, analysis of the distribution of the force revealed RC medical assets as “forward deployed” with regard to a consequential domestic relief mission. Countering this, however, was the fact that medical equipment sets for RC organizations are typically in depot storage and would require a period of weeks to months to be withdrawn and deployed to any unanticipated mission.

Concurrent to these deliberations, multiple evaluative and policy documents were issued that pointed to a need for enhanced medical NBC training. These included multiple analyses by the (then) United States General Accounting Office that addressed a lack of preparedness in medical NBC within the Department of Defense.^2-4

In response to these critiques, the Joint Staff and Army Office of the Surgeon General (OTSG), the latter in its capacity as executive agent for medical NBC training, co-hosted 2 off-site meetings to address medical NBC training.⁵ These meetings resulted in the mutually agreed upon decision to enhance medical NBC training. In parallel, the Department of Health and Human Services (HHS) delivered its 3359 Report to Congress in 2001 that delineated a role for DoD medical assets in domestic response. Ensuing improvements were primarily focused on continuing medical education initiatives, which are limited in availability to the active component and virtually unavailable to RC medical personnel.

The Defense Medical Readiness Training Institute was subsequently tasked by the Assistant Secretary of Defense for Force Health Protection and Readiness to review the Services’ current Chemical, Biological, Radiological, Nuclear and (High Yield) Explosives (CBRNE) medical training and develop a standardized Tri-Service CBRNE Training Program.^{Footnote §} This process built upon existing directives on general military training⁶ as well as training for the RCs,⁷ medical readiness,⁸ and CBRNE specific operations.⁹

The DoD Force Health Protection Council approved the Tri-Service CBRNE Training Program on September 22, 2003. The program consisted of:

• standards of proficiency necessary to support medical CBRNE readiness;

• who needs training;

• the frequency of training;

• a recommended Tri-Service training program (with alternative courses);

• metrics to measure compliance; and

• reporting requirements.

The Standards of Proficiency were developed to provide standardized training to all military medical personnel, including civil service and contract personnel. DMRTI then issued “Chemical, Biological, Radiological, Nuclear, and (High Yield) Explosives (CBRNE) Training—Standards of Proficiency and Metrics,” on October 1, 2003.

Building upon the work of the ad hoc workgroup, the Office of the Chief Army Reserve (OCAR) reviewed multiple existing plans and guidance to identify specified and suggested tasks therein specifically for the Army Reserve medical force. Key documents reviewed included the FRP and ESF 8, the US Army Soldier Biological and Chemical Command (SBCCOM) Improved Chemical Response Plan and SBCCOM Improved Biological Response Plan, and the NDMS plans. These plans were matched against knowledge gained from operational experience in civilian emergency department, hospital administration, and public health leadership roles. This comparison identified skills that would or could be required of DoD medical personnel performing a domestic mission that were not taught at the time.

Conversely, multiple other courses that would be applicable to both traditional missions and Defense Support to Civil Authorities (DSCA) were identified (such as Field Management of Chemical and Biological Casualties, Medical Management of Chemical and Biological Casualties, and Medical Effects of Ionizing Radiation), but these were shown to be administered at different locations, were in addition to mandatory training requirements, and attendance at which was limited by fiscal constraints and quota availability.

For example, the 2000 DoD Annual Report to Congress on Chemical and Biological Defense Program described the Fiscal Year 1999 training throughput of the US Army Medical Research Institute for Chemical Defense (USAMRICD). USAMRICD trained 229 military and non-DoD personnel in its “Field Management of Chemical and Biological Casualties Course” (FCBC), addressing first echelon management of chemical and biological agent casualties.¹⁰

A more extensive USAMRICD offering, “Medical Management of Chemical and Biological Casualties Course” (MCBC). trained 2375 military, non-DoD, and non-US medical professionals. MCBC provides DoD personnel, primarily physicians, physician assistants, and nurses, with a working knowledge of the potential threat of chemical and biological weapons and the status and scope of medical defense strategies.¹⁰

Thirty preventive medicine officers and other medical professionals assigned to deployable units, or directly responsible for NBC consequence management, attended the tri-Service “Medical NBC Readiness Workshop.” This course provided instruction in the medical management of the full spectrum of possible NBC threats, from battlefield NBC scenarios to the conduct of peacetime operations in areas deliberately contaminated with radioactive materials or industrial chemicals.¹⁰

While these numbers seemed significant, it was unclear what impact this training program was having on the ability to augment response to a domestic CBRNE incident. The RCs included some 4500 physicians at the time; a population closer to 3300 today. Of these, how many had attended MCBC? An early 2001 inquiry to USAMRICD posed this question with regard to anyone from the Army National Guard or Army Reserve (Personal conversation, LTC D.A. Donahue and COL B.A. Maliner, February 2, 2001). The sobering answer was “only nine.” Remarkably, this response elicited a surprised follow-up: “Only nine last year?” “No,” came the reply, “nine, ever.” It became abundantly clear that a population that might be seen as a “go to” resource following a chemical or biological attack—military trained medical professionals—did not, in fact, exist.

At the same time, the Army Reserve was examining the state of core medical training and readiness. This review revealed opportunities for improvements that received concurrence from the medical general officers, but which would have to be executed within the existing validated and funded activity level. This would require innovative arrangements and expansion of cooperative training agreements with various outside entities that have historically existed particularly with the Department of Veterans Affairs (VA).

Developing the Strategy

The analysis of potential courses of action to both remedy the persistent shortfalls in medical CBRNE training and proficiency and to prepare for the emerging DSCA mission identified a longstanding, highly successful, and proven concept of prepositioned equipment sets and associated training regimen with that equipment. Most prominent of the examples of this technique was the widespread forward storage of equipment in Europe under the Prepositioning of Material Configured in Unit Sets program and the attendant Return of Forces to Germany (more commonly known by its acronym, REFORGER) exercises. This approach placed required materiel close to the projected deployment site and allowed personnel to be rapidly deployed to “ready to roll” equipment. Moreover, the continuous training rotation facilitated a corresponding maintenance cycle, with equipment sets being rotated through ready, training, and maintenance phases.

The factors that drove the successful Cold War readiness posture dictated the parameters for the establishment of a medical readiness training center that would include both training and deployment support functionality. Desirable characteristics would include availability for joint training, capability to support the initiative, relevance to the US domestic population, and transportation infrastructure to support multiple deployment modalities.

How the Joint/Interagency Civil Support Training Center (JICSTC) Was Established

In 2001, the Chief, Army Reserve (CAR) issued a policy directive that mandated enhanced medical NBC and WMD training in anticipation of the emerging DSCA mission. In 2003, the CAR signed a second medical NBC training policy memorandum that included direction to establish a center of excellence to train for DSCA. This center was to be funded from newly designated homeland security/defense funding, with the added benefit that clinical and operational skills gained from DSCA training would enhance war fighting capabilities as well.

The US Army Reserve Command responded to the CAR’s directive and created the JICSTC at Fort Dix in 2003, as had been envisioned. JICSTC was to be a center of excellence to provide 1-stop training in medical CBRNE and Homeland Security operations and to serve as a response platform for urgent medical missions. JICSTC was designed to be funded through DoD and hosted by the Army Reserve at Fort Dix, New Jersey, leveraging existing training and response capabilities and replicable in 2 other regions to afford total geographic coverage of the Continental United States. Initial operations were established by adding a task order to the Regional Training Site-Medical (RTS-Med) contract and by reallocating resources from the existing 3 RTS-Med sites to JICSTC.

Over the slightly more than 3 y that JICSTC operated, 3032 individuals received unique training. Participants included Active, Guard, and Reserve members, medical and non-medical units, and joint military and civilian assets, as depicted in Table 1. At discontinuation of operations, there was a waiting list for JICSTC rotations driven entirely by word of mouth. The Army Reserve G-3 (Operations) Homeland Defense Office had been planning on conducting casualty decontamination training at JICSTC.Footnote ** ^,11

As a primary source for CBRNE medical response expertise, DoD was envisioned as a logical host for this function. Assumption of the role of host to JICSTC was seen as a logical function for the Army Reserve as it held a major training role within the Army, including for medical personnel. Joint training would be provided to the medical components of the active, National Guard, and reserve forces. It is important to note that while the focus is domestic consequence management,^{Footnote ††} skills and capabilities gained are equally applicable to overseas and wartime missions. This extended interagency process would provide additional training and support to VA, HHS/PHS, DHS, and State Department medical personnel.

JICSTC implementation was coordinated with and approved by the United States Northern Command (NORTHCOM), the Defense Medical Readiness Training Institute (DMRTI), the Assistant Secretaries of Defense (Reserve Affairs) and (Health Affairs), the Under Secretary of Defense (Personnel and Readiness), the DHHS Office of Emergency Response, and VA. The concept was later endorsed by the DHS Office of Health Affairs and the Uniformed Services University of the Health Sciences; the latter institution incorporating JICSTC into the strategic plan for its Center for Disaster and Humanitarian Assistance Medicine.

While the ability to respond to any location within the Continental United States would appear to dictate multiple locations, a single location was decided upon to launch the initial effort. The contiguous Fort Dix, McGuire Air Force Base, and Naval Air Engineering Center Lakehurst complex was selected to launch the prototype effort. Factors that supported establishment of JICSTC at this location are delineated in Table 3.

TABLE 3 Planning Factors Favoring the Fort Dix Location

Immediate Acceptance and Success

JICSTC enjoyed almost immediate acceptance and success. Even before the first course was launched, the Air Force Reserve Command Surgeon inquired as to when he could begin sending students to the Center. Because formal designation as a DoD-sanctioned course was never pursued, JICSTC was not listed in the formal training catalog, the Army Training Requirements and Resources System. Requests for training were, therefore, driven by word of mouth. This proved to be sufficient to support operations for the 3 y JICSTC operated.

A major contributing factor to the success of JICSTC was the exceptional support provided by several organizations committed to the training mission. Primary among them was the USARC NBC section that provided chemical decontamination and operations training, the New Jersey National Guard which provided modeling and simulation support, and Fort Dix itself which hosted the Center for its entire span of operations. JICSTC trained members from all 3 Army components—Active, Guard and Reserve—plus Navy Reservists and civilians.

JICSTC was envisioned to include integration of existing courses, such as revised and abridged versions of the FCBC and MCBC. Coordination of this aspect was completed but could not be executed until formal funding was implemented.

Among the successes of JICSTC was the introduction of DSCA-focused courses, such as the overview of the FRP and the successor National Response Plan, orientation to the Incident Command System, and Medical Aspects of Urban Search and Rescue, a course unique to this training endeavor. The urban search and rescue course and exercise proved to be extraordinarily popular, with 1 hospital commander telling the instructor cadre that it was the best technical and teambuilding exercise he had ever encountered. Significantly, prior and current military medical training does not include intense instruction on collapsed structure medicine, an environment in which the victim and the rescuer are both at risk for injury or death.

Post training cycle surveys were administered. These were unfortunately lost upon the discontinuance of JICSTC operations. Student feedback was nearly universally positive, including statements such as that made by the clinic commander at Fort Monmouth, who indicated his intention to send his entire staff to JICSTC. The Air Force Reserve Command Surgeon inquired about sending teams to the training and a waiting list was created to document interest and schedule future training rotations.

The plans for JICSTC included several other classes that were identified in the review of existing courses, such as Risk Communication (both to the public and with the media), Mass Pharmaceutical Distribution for Non-Pharmacy Medical Personnel, and Basics of Forensic Dentistry. This were to be implemented through the cooperation of and under the auspices of affiliated universities and select faculty who are recognized subject matter experts (SMEs) and coordinated with DMRTI to link to DoD Medical Training Standards.

JICSTC would also incorporate already established and emerging offerings from outside DoD, such as the Centers for Disease Control and Prevention (CDC) initiative Basic Disaster Life Support (BDLS) and Advanced Disaster Life Support (ADLS) courses, now maintained and promulgated by the independent National Disaster Life Support Foundation.

Lastly, JICSTC was envisioned as a test bed that would allow the examination of best practices from DoD, other Federal agencies, and from academia. As a joint and interagency forum, JICSTC would be uniquely positioned to foster cross training, familiarization with disparate shelter systems and medical equipment sets, and organizational processes. This would support a research and development functionality that would span the range of clinical acumen, procedures and techniques, and materiel. The seeds of this cross-fertilization were witnessed in the participation of students from diverse organizations. Full realization of this capability would rely, however, on full scale operation of JICSTC.

Snatching Defeat From the Jaws of Victory

As JICSTC was being established, full funding was secured by means of a Program Budget Decision (PBD) issued by the Office of the Assistant Secretary of Defense (Reserve Affairs). The PBD, offered in Fiscal Year 2003, dedicated $63.5 million for the initial 5 y of JICSTC operations pending inclusion in the Army Program Objective Memorandum (POM) process. In Fiscal Year 2004, this amount increased to $66.0 million. Transfer and execution of this funding was dependent on acceptance by the executing command. The Chief of Operations for the Office of the Chief, Army Reserve (OCAR) deferred to OTSG as the executive agent for medical NBC training. The program manager at OTSG also declined this funding, stating “I don’t know that this is our mission… Why would we want to do that?”

Concurrently, the formal approval process was being pursued for JICSTC to be authorized as a formal DoD institution. An Operational Requirement Document (ORD) was drafted, endorsed by DMRTI and NORTHCOM, and approved by the Office of the Assistant Secretary of Defense (Health Affairs). A subsequent Initial Capabilities Document (ICD) was drafted, but never submitted following the declination of funding by the executive agent and the retirement of the staff officers who were promoting the JICSTC initiative.

Conceptualization and creation of JICSTC was coordinated by the medical operations staff at OCAR. This effort was supported by the USARC Surgeon, 2 successive Directors of Domestic Emergency Preparedness - Medical Programs (Military Assistance to Civil Authorities) within Reserve Affairs, the Army Deputy Surgeon General for Mobilization, Readiness and Reserve Affairs, and the Army Surgeon General.

During the latter half of its operational lifespan, all of these individuals either retired or were rotated to other assignments. The successor USARC Surgeon did not support continuing JICSTC operations and, in fact, briefed USARC leadership that DoD did not support this mission within the Army Reserve. The draft ICD was never forwarded for approval and given several cycles of personnel turnover, the offered funding from Reserve Affairs was never pursued, leading to its eventual withdrawal. Because it was not seen as a priority and the Army was unaware of the potential funding, JICSTC was not included in the approved POM resourcing. Given the lack of command support and attendant funding, operations of JICSTC as an unfunded initiative were ceased on September 30, 2006.

The benefit of a supplemental training, maintenance, and deployment platform that addressed a nascent domestic mission while enhancing core combat capabilities was forfeited as the operational focus shifted to Afghanistan and Iraq. Now, more than a decade later, there is no indication of a substantially improved capability to respond to a catastrophic disaster. Myriad capabilities exist, but are disjointed or rely on overly optimistic assumptions.^{Reference Donahue, Godwin and Cunnion12} NDMS training and deployment capabilities remain limited due to budgetary constraints.^{Reference McCann13} Ominously, the need for a robust, comprehensive medical response capacity has never been greater.

The slow but steady expansion of nuclear weapons capabilities, the proliferation of industrial and medical radiation sources with minimal or questionable security safeguards, and an abundance and variety of non-state actors committed to terrorism underscores the need for a Nuclear Global Health Workforce.^{Reference Burkle and Dallas14} Novel diseases are emerging and travelling at an unprecedented pace.¹⁵ Since the original JICSTC ceased operations, there have been 5 declarations by the World Health Organization of a Public Health Emergency of International Concern (PHEIC)^{Footnote ‡‡} and multiple significant outbreaks that did not meet the standard to be designated a PHEIC, eg, MERS-CV. More people are now refugees or internally displaced than at any time in history. And there is a willingness of states to use chemical weapons at home and abroad unseen since World War I.

Reviving the Concept: The Need Persists

The JICSTC concept remains relevant. Major gaps in domestic disaster medical response capabilities have been recognized for more than 2 decades. Experts from the Institute of Medicine,¹⁶ United States Northern Command,^{Footnote §§ ,17} and multiple academic centers and professional organizations^{Reference Franco, Toner and Waldhorn18} have identified these shortcomings, but the national response posture remains disjointed, under-resourced, and based upon obsolete planning premises. Coordinated federal response capabilities are seen as formidable, but in reality address niche needs and do not offer a comprehensive and encompassing response.^{Reference Donahue, Godwin and Cunnion12} The 2014 Ebola incidents and recent Blue Ribbon Study Panel on Biodefense¹⁹ serve to underscore the perpetuated risk of medical disaster response deficits.

The intent for JICSTC was to create 3 sites, located in such a manner as to offer relative geographic proximity to all 56 states and territories. The centers will provide unique course content based on experience and research into the evolving needs of a post-disaster society. Projected locations are based upon geographic proximity to the US population, availability of multiple deployment modalities, and available support infrastructure. The establishment of 3 National Health Preparedness and Response Centers would enable major federal response within 24 hours, reducing equipment maintenance costs, and fulfilling the goals of the 2007 Homeland Security Presidential Directive/HSPD-21, Public Health and Medical Preparedness.

The value of a rapid medical response was demonstrated following the destruction, by an EF-5 tornado, of St. John’s Regional Medical Center in Joplin, Missouri on May 22, 2011. An 8000 square foot (743.2 m²) mobile field hospital from the Missouri Disaster Medical Assistance Team (DMAT) was available some 110 road miles away in Branson, having been deployed for the 2011 National Level Exercise. This facility was moved to Joplin, allowing the St. John Regional staff to resume providing limited care on May 29th.^{Reference Winters20}

This same experience also highlighted shortcomings in the current system. The 6 days between the twister’s impact and the resumption of local health-care capacity left a gap in the ability to treat immediate injuries and conditions, such as fractures, penetrating wounds, pneumonia, mucormycosis, and others resulting from the storm. Quicker establishment of alternative treatment venues would invariably improve outcomes, the extent of which being dependent on the specific disaster.

The ability to locate the alternative health-care facility close to the disaster’s impact would increase access and facilitate patient transport. The deployment of the hospital ship USNS Comfort to Puerto Rico following Hurricanes Irma and Maria provided a state of the art, 1000 bed medical center. The administrative and logistical challenges of accessing the floating medical center severely limited the benefit of its presence.^{Reference Robles and Fink21}

The training and response centers would be unique venues differentiated by distinctive characteristics. Training will be conducted on the equipment that would be actually used in response to a disaster. In what has been described as the “firehouse model,” this familiarizes responders to the equipment, identifies incompatibilities, and creates an inherent maintenance and upgrade cycle that has been shown to dramatically reduce operational costs. Ideally, 3 sets of equipment would be prepositioned at each site: 1 used for training, 1 moved into maintenance after training use, and the third in a “go” status after maintenance; all in a continuous cycle.

Current world crises are increasingly coordinated under a multidisciplinary and trans-disciplinary framework. Health-care providers, as just 1 element, no longer focus on the response phase alone of the disaster cycle, but need to be equally proficient in prevention, preparedness, response, recovery, and rehabilitation.^{Reference Burkle22}

The JICSTC experience was notable because it brought together military, civil, academic, non-governmental, and professional society representation into an ongoing, hands-on experience that also served as a research laboratory. This produced unexpected, significant insights. Early on, during a collapsed structure treatment exercise, instructors sounded an intermittent horn blast. Military participants stopped and donned chemical protective masks, the horn sounds being the accepted signal for a chemical attack. Participants who were members of an urban search and rescue team immediately fled the area. It was at this point learned that intermittent horn blasts are the signal for an imminent collapse in urban search and rescue. It became clear that different communities used like signals for divergent reasons, placing all but 1 in immediate peril at the sounding of the signal.

The knowledge, skills, and abilities developed and honed by the military health community for addressing the impact of CBRNE events in conflict are directly applicable to such events occurring domestically, whether deliberate or accidental. The military has arguably unparalleled ability to project comprehensive medical services to remote and austere environments, irrespective of whether the need derives from conflict, natural disaster, or intentional acts. The greater integration of this capability, including the diffusion of technical expertise across the domestic response infrastructure, stands to enhance the nation’s resiliency.

During the writing and review of this manuscript, it has been suggested that what is needed

While this is an argument left for another day, the authors propose that reestablishment of a successful training and response initiative would be a powerful next step toward enhanced preparedness.

The anticipated collaboration of an academic consortium, diverse professional societies with a common goal, and a military-public-private partnership would provide definitively enhanced resilience and response capabilities on a national level. Unique linkages to degree programs, provision of continuing medical and professional education, creation of a common operating language, fostering of interoperability, certification, and registration of skills, decreased equipment maintenance costs, and increased responsiveness to a catastrophic or other significant disaster are the immediate benefits of this project. The long-term return of this operational concept has the potential to save countless lives.