Medical CBRN Defence in the Australian Defence Force

By Neil Westphalen In   Issue Volume 27 Number 1 .

Major David J Heslop, Commander Neil Westphalen

Introduction

This article focuses on a specialist area of military medicine, following a series of recently published papers regarding occupational and environmental medicine in the ADF.1 They assert that high rates of preventable workplace illness and injury indicate the need to improve the management of occupational and environmental hazards associated with ADF workplaces, with better emphasis on prevention rather than treatment.

These papers advocate that, rather than replicating the treatment services used for Australian civilians, the ADF’s health services should be premised on an occupational and environmental health paradigm. For this to occur, the health capability gaps in the current ADF health service delivery model demand reassessment of the fundamental inputs to (health) capability, for both Joint Health Command (JHC) and Defence’s Work Health and Safety Branch.

Such a reassessment, with implementation of necessary changes, could lead to a holistic and sustainable workforce-based ADF health service delivery model by 2030.This timeframe is based on the current state of the ADF’s occupational and environmental health services, and the small number of civilian specialist practitioners within the Australasian Faculty of Occupational and Environmental Medicine (AFOEM).These considerations suggest that a mature health delivery model would take 10–15 years’ sustained effort, with respect to occupational and environmental physicians alone.2

This article expands on the previous papers, with respect to how such a paradigm is essential to the ADF’s defensive medical Chemical, Biological, Radiological and Nuclear (CBRN) capabilities.

Global CBRN Threats

Hunter-gatherer communities have used biological weapons such as poisoned-tipped spears and arrows since prehistoric times. However, the first documented use of a biological agent for warlike purposes was in 1346, when plague-infected corpses were catapulted into the city of Caffa (now Feodosia in Crimea) by besieging Mongols. Even so, it was not until the mid-19th century that investigators, such as Louis Pasteur in France and Robert Koch in Germany, demonstrated that microorganisms could cause disease, while research into the industrialised weaponising of potential biological agents only began during World War I (WWI).3

Lethal chemical weapons were first used in 1915 by the Germans near Ypres on the Western Front.4 The century since has seen many nations develop, and sometimes utilise, a chemical weapons capability.5 Although nuclear weapons were used twice in 1945,6 other radiological weapons have so far not been employed on a mass scale.7,8,9

Since the end of the Cold War, most CBRN events have usually entailed the use of chemical and biological weapons by non-state terrorist organisations.10 Examples include the 1995 attack on the Tokyo subway by the Aum Shinrikyo cult using sarin,11 and the 2001 attack on the US Senate and two media outlets by unknown perpetrators using anthrax.12

The development, production, stockpiling and use of chemical weapons is prohibited by the 1997 Chemical Weapons Convention,13 while the 1975 Biological Weapons Convention likewise prohibits that for biological weapons.14 Nuclear weapons are presently subject to the 1963 Partial Nuclear Test Ban Treaty15 and the 1970 Nuclear Non-Proliferation Treaty.16,17

However, several nations have not signed or ratified some or any of these treaties. In addition, North Korea withdrew from the Nuclear Non-Proliferation Treaty in 2003,18 and has recently threatened several regional neighbours, including Australia, with nuclear weapons.19 Moreover, these treaties lack relevance with respect to compliance by non-state non-signatories, such as terrorist organisations. CBRN weapons therefore, remain an important global threat.

Furthermore, the goals and actions of non-state terrorists in recent years have made the use of CBRN weapons more likely, while technological advances have made their use more feasible.20 Given the victims of a CBRN attack may vary from individuals to whole populations – which may include military personnel as well as civilians21 – defending against these weapons has become an important public health issue.22

Many nations including Australia have therefore focused their defensive CBRN measures against the public health threat posed to their civilian populations by terrorist organisations, particularly after the 2001 World Trade Center terrorist attacks.23 This approach predicates managing health responses to deliberate CBRN terrorist attacks that are intended to cause harm, on comparable terms as for accidental hazardous material incidents.24

This article therefore, contends that occupational and environmental medicine has an important role with respect to commanders applying a risk management approach to the prevention and treatment of CBRN casualties, while maintaining ADF operational capability.

Civilian CBRN Defence in Australia

Within Australia, the primary responsibility for protecting life, property and the environment lies with the states and territories. Each of these have their own plans and arrangements to respond to, and recover from, natural and human-caused emergencies. To this end, some state and territory health departments have dedicated disaster management units.25

To complement their efforts in responding to emergencies, the Australian Government can also provide physical and financial assistance. This is an Attorney-General’s Department responsibility through Emergency Management Australia (EMA).26

Australia’s civilian CBRN defensive measures are generally incorporated into a unified ‘All Hazards’ approach, for a range of different emergencies. Local authorities initially respond to these emergencies, followed by a series of escalatory stages. In addition, EMA has specific health guidance for dealing with CBRN hazards.27

ADF CBRN Defence

For a medium-sized power, Australia’s involvement with CBRN issues has been surprisingly intimate. This began in WWI, where 323 Australian Imperial Force (AIF) personnel died and 16,426 were wounded by gas on the Western Front.28 Although they were not used, Australia stockpiled its own chemical weapons during WWII, as a deterrent against theJapanese.29 Australia then provided three sites and about 15,000 personnel for 12 British nuclear weapons tests between 1952 and 1957.30

More recently, the Australian deployments before and during the 1990-91 Gulf War were conducted in what was assessed as a high-threat chemical and biological warfare environment.31 Australians then participated in a series of United Nations CBRN weapons inspections in Iraq.32

The ability of ADF personnel at sea, on land and in the air to maintain operational capability before, during and after a CBRN attack remains fundamental to defending Australian interests. To this end, all ADF personnel undergo basic CBRN defensive training on entry and periodically thereafter (typically every five years). It usually takes only one day and is generally limited to describing the various types of CBRN hazards and practical demonstrations of respirators and other CBRN equipment. Navy incorporates this training into its non-CBRN shipboard damage control courses.33

Additional training is provided for the relevant instructors and for specific deployments that are assessed as posing a greater CBRN threat.

ADF health support in CBRN environments is based on self- and buddy-aid, which are time-critical and complicated by the risk of further contamination. After decontamination, casualties require further specialist CBRN treatment, perhaps concurrently with resuscitation for other life-threatening injuries.

Current ADF operational doctrine for CBRN defence is therefore predicated on five pillars – Detection, Identification and Monitoring (DIM); Warning and Reporting (W&R); Physical Protection; Hazard Management and Medical Countermeasures (MCM); and Medical Support. Although the medical contributions are predominantly centred on the final pillar, they still include all the others, which can be summarised as:

CBRN occupational screening. This ensures that at-risk personnel meet the appropriate physical, medical and psychological standards. This particularly refers to personal protective equipment suitability, fitting and kitting. The standards are difficult to justify, and are often subsumed within broader medical standards, where their justification can be lost.

CBRN medical preparation. This includes physical conditioning activities, vaccinations, providing personal medical countermeasures and CBRN first aid items. Apart from high readiness elements, this is usually conducted ‘just-in-time’. It is also contingent on sufficient quantities of in-date vaccinations and CBRN medications being available when required, typically when other nations are competing for the same items simultaneously.

CBRN medical training. This refers to the medical theory and recognition of CBRN agents, how to use personal medical countermeasures, protocols for self- and buddy-aid, casualty evacuation, decontamination and integrating each of these individual medical activities into overall CBRN defences. This training tends to have a heavy theoretical component, is generally scenario-based and is difficult to access.

In support of integrating wider activities across these pillars and their related medical activities, the ADF has an extensive range of non-health CBRN policy references.34 Additional guidance is also available from a range of NATO35 and other references.

The development and maintenance of CBRN-related health policy, doctrine and procedures, and providing health input into strategic CBRN policy and doctrine, is a JHC responsibility.36 However, at present, JHC lacks the dedicated specialist health staff necessary to perform these tasks. Furthermore, JHC does not have a dedicated ADF CBRN health manual. Instead, extant guidance is dispersed among and within multiple operational health references.37

Current recruiting health standards38 for ADF members do not include factors such as CBRN respirator compatibility with their spectacles, CBRN personal protective equipment compatibility with their height and weight, or medical conditions that may restrict their ability to use CBRN countermeasures.39 While these factors may not affect their ability to undertake their normal duties, it may limit or preclude ADF members from doing so in a CBRN environment. Such cases should therefore be identified before they are called upon to do so.

Apart from self- and buddy-aid, basic periodic CBRN training does not include on-scene casualty treatment or specialist toxicological and emergency management; since 2012, these capabilities have resided only within Army’s Special Operations Engineer Regiment (SOER). SOER originated in 1999 as the Joint Incident Response Unit (JIRU), as part of the ADF’s security arrangements for the 2000 Sydney Olympics. JIRU was formed from amalgamating several specialised Royal Australian Engineer units, including its Chemical Biological Radiological Response (CBRR) Squadron.40

The intent of CBRN training for military health personnel is to conserve fighting strength, continue providing non-CBRN health services and support to the maximum extent possible, protect health personnel from CBRN injuries, minimise CBRN morbidity and mortality, avoid the spread of contamination into health vehicles and facilities, and provide command advice.

To this end, various Army and Navy units have conducted medical officer CBRN courses over many decades. Apart from a hiatus in 2003, these courses were centralised at the Army Logistic Training Centre from 1994 until 2007.Besides Australian CBRN subject matter experts, these courses employed presenters from the US Army Medical Research Institute of Infectious Diseases (USAMRIID),41 the US Army Medical Research Institute of Chemical Defense (USAMRICD)42 and the US Armed Forces Radiobiology Research Institute (AFRRI).43 These together arguably constitute the Western world’s centres of medical CBRN expertise.

CBRN training for ADF health personnel has been a JHC responsibility since 2009.To this end, the ADF Medical Officer CBRN course was updated in 2011 to incorporate advances in technology and medical practice. Its intent was to teach Permanent and Reserve medical officers, nursing officers and senior ADF medics how to apply their existing medical skills to treat CBRN casualties.44 Although the updated CBRN Health Course was piloted in 2012, it has not been conducted since.45

Implications

Like many other military organisations, for many years it has been ADF practice to deliver basic defensive CBRN instruction during entry training, followed by limited periodic refresher CBRN courses. Additional training is provided for the relevant instructors and for specific deployments that are assessed as posing a greater CBRN threat.

The rationale for this approach stems from the substantial personnel and other resources necessary to sustain a high level of CBRN preparedness. While this gives every permanent and many reserve ADF members at least some CBRN familiarity, it does not provide the specialist medical or non-medical expertise required to develop and implement strategic-level CBRN policy and doctrine.

Furthermore, nearly 30 years after it ended, the current ‘just-in-time’ approach still reflects Cold War doctrine, despite the goals and actions of non-state terrorists making the use of CBRN weapons more feasible and likely. In particular, this approach does not address unforeseen CBRN threats to ADF personnel that may arise mid-deployment or even within Australia.

The ADF’s ability to treat its own and other military CBRN casualties is presently constrained to that which can be provided by SOER, which is limited to its supporting and enabling role for Special Operations in general. Additional training is required for health staff who support and enable the ADF’s non-Special Operations capabilities, in particular its Role 2 health units46 such as Army’s 1st Close Health Battalion47 and Navy’s Maritime Operational Health Unit.48

Yet, the fact that there has been no CBRN health course since 2012 means that JHC’s ability to conduct one has probably atrophied, to the point where it would more-or-less entail starting from scratch. Even with overseas assistance, reconstituting the breadth and depth of specialist health CBRN expertise within the ADF to conduct this course will take several years, at a time when the use of CBRN weapons by terrorist organisations in particular, is more feasible and likely.

In any event, future ADF CBRN health courses should still employ the expertise provided by USAMRIID, USAMRICD and AFRRI, either directly to course participants, or indirectly through ‘train-the-trainer’ courses. Additional clinical CBRN refresher training should be also provided on the same terms as other clinical refresher training, such as the Advanced Trauma Life Support course.

The lack of CBRN expertise within JHC also compromises CBRN health policy currency and precludes providing higher-level CBRN policy and doctrine health input. Furthermore, incorporating extant CBRN health policies into JHC’s generic operational health guidance implies that they are not considered a high priority.

The relevance and importance of occupational and environmental medicine to the broader ADF has previously been highlighted.49 In this instance, among their other attributes, occupational and environmental physicians undergo comprehensive theoretical and practical education with respect to applying a risk management approach to the medical aspects of preventing, assessing, managing, treating and advising on biological, chemical, radiological and other hazards.50

Military occupational and environmental physicians therefore, already possess many of the skill sets required to provide specialist CBRN health training, policy development and command advice. Their participation would also be predicated on managing CBRN hazards on comparable terms as other military occupational and environmental hazards. As applied to the ADF population, this approach is consistent with current national guidance for managing CBRN attacks on Australian civilians, while also maintaining ADF operational capability.

This paper therefore contends that, in collaboration with other occupational and environmental health practitioners and CBRN subject matter experts, occupational and environmental physicians have much to offer the ADF, with respect to leading and sustaining a holistic and time-critical responsive CBRN health planning, preparation and operational response capability.

Conclusion

With ADF personnel arguably exposed to the most diverse range of occupational and environmental hazards of any Australian workforce, high rates of preventable workplace illness and injury indicate the need to improve the management of occupational and environmental health hazards with better emphasis on prevention than treatment. This includes the accelerated pace and reduced warning of future CBRN threats to ADF personnel.

These considerations suggest that the ADF’s health services be premised on an occupational and environmental health paradigm, with revised fundamental inputs to capability that would lead to a genuinely holistic and sustainable workforce-based ADF health service delivery model by 2030.

Among other attributes, this paradigm would entail military occupational and environmental physicians, who already possess many of the specialist skills to manage CBRN hazards, on comparable terms as other occupational and environmental hazards.

Many nations, including Australia, have focused their CBRN defensive measures against the civilian public health threat posed by terrorist organisations. Military occupational and environmental physicians can apply the same approach to the ADF population, with respect to the prevention and treatment of CBRN casualties, while also maintaining operational capability.

Authors

Major David Heslop graduated his PhD in medicine in 2004 and medicine in 2006 from The University of Sydney as part of the ADF Graduate Medical Scheme, is a Fellow of the Royal Australasian College of General Practitioners and active clinician, and an advanced fellowship trainee with the Australasian Faculty of Occupational and Environmental Medicine. He is currently an Associate Professor at the School of Public Health and Community Medicine at University of New South Wales, Sydney specialising in disaster, CBRNE and health systems research. He has extensive training and experience with the military in CBRNE medicine, medical operations planning and execution and developing medical capability for austere environments. He has deployed on humanitarian assistance and community relief roles, OP SLIPPER and OP RESOLUTE. He was the Officer Commanding and Senior Medical Officer at the CBRN medical troop of the Special Operations Engineer Regiment from 2013-2015 and has ongoing responsibilities as Senior Medical Adviser CBRNE medicine to elements of Special Operations Headquarters.

Dr Neil Westphalen graduated from Adelaide University in 1985 and joined the RAN in 1987.He is an RAN Staff Course graduate and a Fellow of the Royal Australian College of General Practitioners, the Australasian Faculty of Occupational and Environmental Medicine, and the Australasian College of Aerospace Medicine. He also holds a Diploma of Aviation Medicine and a Master of Public Health.

His seagoing service includes HMA Ships Swan, Stalwart, Success, Sydney, Perth and Choules. Deployments include DAMASK VII, RIMPAC 96, TANAGER, RELEX II, GEMSBOK, TALISMAN SABRE 07, RENDERSAFE 14, SEA RAIDER 15, KAKADU 16 and SEA HORIZON 17.His service ashore includes clinical roles at Cerberus, Penguin, Kuttabul, Albatross and Stirling, and staff positions as J07 (Director Health) at the then HQAST, Director Navy Occupational and Environmental Health, Director of Navy Health, Joint Health Command SO1 MEC Advisory and Review Services, and Fleet Medical Officer (2013-2016).

Commander Westphalen transferred to the Active Reserve in July 2016.

 

Disclaimer

The views expressed in this article are the authors, and do not necessarily reflect those of the Australian Army, the RAN or any of the other organisations mentioned.

Corresponding Author: Neil Westphalen, neil.westphalen@bigpond.com Authors: N Westphalen1, D Heslop2

Author Affiliations:

1 Royal Australian Navy Reserve

2 University of New South Wales, School of Public Health and Community Medicine

 

Acknowledgements

References

  1. Westphalen, ‘Occupational and environmental medicine in the Australian Defence Force’ Australian Defence Force Journal, 2016 Issue 200, pp.49-58, available from <http://www.defence.gov.au/ADC/ ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf; also N.Westphalen, ‘Primary Health Care in the Australian Defence Force’, Australian Defence Force Journal, 2017, Issue 202, pp.91-97, available from <http://www.defence.gov.au/adc/adfj/Documents/issue_202/Westphalen_July_2017.pdf; also N.Westphalen, ‘Assessing medical suitability for employment and deployment in the Australian Defence Force’, Australian Defence Force Journal, Issue 203, January 2018, pp.67-74, available at http:// www.defence.gov.au/adc/adfj/Documents/issue_203/ADF%20Journal%20203_Article_Westphalen.pdf
  2. Australia’s future health workforce – doctors’, Health Workforce Australia 2014, , Australian Government Health, available from http://www.health.gov.au/internet/main/publishing.nsf/Content/ F3F2910B39DF55FDCA257D94007862F9/$File/AFHW%20-%20Doctors%20report.pdf.
  3. See Carus, W.S.‘A short history of biological warfare: from pre-history to the 21st century’, Occasional Paper 12, Center for the Study of Weapons of Mass Destruction, National Defence University, Washington DC, August 2017, available from http://ndupress.ndu.edu/Portals/68/Documents/ occasional/cswmd/CSWMD_OccasionalPaper-12.pdf.
  4. See Heller, CE.‘Chemical Warfare in World War I: The American Experience, 1917 – 1918’, Leavenworth Research Paper No 10, Combined Arms Research Laboratory, available from https://www.webharvest.gov/peth04/20041017045619/http://www.cgsc.army.mil/carl/resources/csi/Heller/HELLER.asp#1
  5. During the interwar period, chemical weapons were used by the Italians against Ethiopians, and by the Japanese against the Chinese.Since WWII, they have been used by the Egyptians against Yemenis, Iraqis against Iraqi Kurds and Iranians, and most recently by the Syrians against rebels in 2013 and 2017.See Evison, D, Hinsley D, Rice P, ‘Chemical weapons’, British Medical Journal, 09 February 2002, Vol 324 No 7333 pp 332–335 available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122267/df; and Cumming-Bruce, N, ‘U.N.panel faults Syria’s military for chemical attack’, New York Times ,available from https://www.nytimes.com/2017/09/06/world/middleeast/syria-chemical-weapons.html?mcubz=0.
  6. For a contemporaneous description, see ‘The Atomic Bombings of Hiroshima and Nagasaki, by The Manhattan Engineer District, June 29, 1946’, available from http://www.atomicarchive.com/Docs/ MED/index.shtml.
  7. Operation PEPPERMINT refers to US preparations to counteract the use of radioactive poisons by the Germans, to disrupt of the 1944 Allied landings in Normandy.Fortunately, it transpired that the Germans had no such weapons.See ‘Operation Peppermint’, available from https://www.revolvy.com/ main/index.php?s=Operation%20Peppermint.
  8. A radiological weapon using Polonium-210 was used to assassinate former Russian secret service officer Alexander Litvinenko on 23 November 2006.See White, RF, ‘Assassination Discourse and Political Power: The Death of Alexander Litvinenko’, 2008, available from http://www.assassinationresearch.com/v5n2/v5n2white.pdf.
  9. For an example of a radiological contamination accident resulting in mass civilian casualties, see ‘The Radiological Accident at Goiânia’, International Atomic Energy Agency, 1988, available from http:// www-pub.iaea.org/mtcd/publications/pdf/pub815_web.pdf.
  10. A probable exception was the assassination of Kim Jong-nam, in Kuala Lumpur on 13 February 2017 using VX nerve agent.His assassination has not been ascribed to a non-government terrorist organisation, but the North Korean government.See Colvin, M, ‘Nerve agent VX used to kill estranged half-brother of Kim Jong-un’, ABC News, 24 February 2017, available from http://www.abc.net.au/ pm/content/2016/s4625889.htm.
More recently, the Russian government was implicated in an assassination attempt in March 2018 on former Russian secret service officer Sergei Skripal using Novichok nerve agent.The attack put himself, his daughter, a policemen and two bystanders in hospital, one of whom died.See ‘Skripal poisoning suspects reportedly identified amid doubt over eventual arrests’, ABC News, 20 July 2018, available from http://www.abc.net.au/news/2018-07-19/novichok-attack-on-the-skripals-suspects-reportedly-identified/10014420
  1. Pletcher, K, ‘Tokyo subway attack of 1995’, Encyclopaedia Britannica, available from https://www.britannica.com/event/Tokyo-subway-attack-of-1995.
  2. See ‘Amerithrax Investigative Summary’, Federal Bureau of Investigation, 19 February 2010, available from https://www.justice.gov/archive/amerithrax/docs/amx-investigative-summary.pdf.
  3. ‘Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on Their Destruction’, Organisation for the Prohibition of Chemical Weapons, 1994, available from https://www.opcw.org/fileadmin/OPCW/CWC/CWC_en.pdf.
  4. ‘Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction’, The United Nations Office at Geneva, available from https://www.unog.ch/80256EDD006B8954/(httpAssets)/C4048678A93B6934C125718 8004848D0/$file/BWC-text-English.pdf.
  5. No 6964: Treaty banning nuclear weapon tests in the atmosphere, in outer space and under water, available from https://treaties.un.org/doc/Publication/UNTS/Volume%20480/volume-480-I-6964- English.pdf.
  6. ‘Treaty on the Non-Proliferation of Nuclear Weapons’, United Nations Office for Disarmament Affairs, available from http://disarmament.un.org/treaties/t/npt/text.
  7. The Comprehensive Nuclear-Test-Ban Treaty was opened for signature in 1996, but has not yet entered force.See ‘Comprehensive Nuclear-Test-Ban Treaty (CNBT)’, United Nations Office for Disarmament Affairs, available from https://www.un.org/disarmament/wmd/nuclear/ctbt.
  8. See ‘North Korea’s Withdrawal from the Nuclear Nonproliferation Treaty’, American Society of International Law, 2003 , Vol 8 No 2, available from https://www.asil.org/insights/volume/8/issue/2/ north-koreas-withdrawal-nuclear-nonproliferation-treaty.
  9. See Palin, M, Crew V, ‘North Korea warns Australia has committed a ‘suicidal act’’, 22 August 2017, news.com.au, available from http://www.news.com.au/technology/innovation/north-korea-warns-us-is-pouring-gasoline-on-fire/news-story/1921b8c27c4cf6dd64ce18c7196ead97.
  10. Sweijs, T, Kooroshy, J, ‘The future of CBRN’, The Hague Centre for Strategic Studies, 2010, Future Issue No 12, available from https://www.hcss.nl/sites/default/files/files/reports/HCSS_12_03_10_ The_Future_of_CBRN.pdf.
  11. Although CBRN weapons were not involved, for an Australian example see Zammitt, A, ‘The Holsworthy Barracks plot: a case study of an Al-Shabab support network in Australia’, Combating Terrorism Centre, 21 June 2012, available from https://ctc.usma.edu/posts/the-holsworthy-barracks-plot-a-case-study-of-an-al-shabab-support-network-in-australia.
  12. Mazzone, A, ‘The Use of CBRN Weapons by Non-State Terrorists’, Global Security Studies, 2013, Vol 4 No 4, available from http://globalsecuritystudies.com/Mazzone%20CBRN-AG.pdf.
  13. See National Commission on terrorist attacks on the United States ‘911 Commission Report’, available from https://www.9-11commission.gov/report/911Report.pdf.
  14. Examples of mass casualty hazardous material accidents include the industrial accident at Seveso Italy in 1976, and the disaster in Bhopal India in 1985.See ‘Icmesa chemical company, Seveso, Italy.10th July 1976’, Health and Safety Executive, available from http://www.hse.gov.uk/comah/sragtech/ caseseveso76.htm; and Bowater, B, ‘An analysis of the Bhopal accident’, Project Appraisal, 1987 , volume 2, number 3, pp157-168, available from http://www.tandfonline.com/doi/pdf/10.1080/02688 867.1987.9726622.
  15. For example, the Western Australian Department of Health’s Disaster Preparedness and Management Unit has a range of public health policy, planning and training programs.See ‘Disaster Management’, Government of Western Australia Department of Health, available from http://ww2.health.wa.gov.au/ Health-for/Government-and-NGO/Disaster-management.See also NSW Health Medical Services Supporting Plan, available from http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/ GL2010_011.pdf; ‘Emergency Type’, Health.Vic , , available from https://www2.health.vic.gov.au/ emergencies/emergency-type; ‘Queensland Health’s role in a disaster’, Queensland Health, available from https://www.health.qld.gov.au/public-health/disaster/management; ‘Emergency incident and disaster management’, SA Health, available from http://www.sahealth.sa.gov.au/wps/wcm/connect/ Public+Content/SA+Health+Internet/Health+services/Ambulance+and+emergency+services/Emergency +incident+and+disaster+management; ‘Plan for the Delivery of Integrated Emergency Management within the Department of Health and Human Services and Tasmanian Health Organisations’, Tasmanian Department of Health and Human Services Emergency Preparedness and Coordination Unit, available from http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/156144/PDIEM_DHHS_ and_THOs.pdf; ‘Health Disaster Management’, NT Department of Health, available from https://health.nt.gov.au/health-governance/department-of-health/health-disaster-management/introduction.
  16. ‘Emergency Management Australia’, Attorney General’s Department, available from https://www.ag.gov.au/EmergencyManagement/Emergency-Management-Australia/Pages/default.aspx.
  17. See Emergency Management Australia, Health Aspects of Chemical, Biological and Radiological (CBR) Hazards (Provisional).Manual Number 13.National Capital Printing, 2000.
  18. See Butler, A.G.Official History of the Australian Army Medical Services, 1914–1918, Volume 3 Chapter 17, Table 26.Australian War Memorial, 1943.
  19. See Plunkett, G.Chemical Warfare in Australia: Australia’s Involvement in Chemical Warfare 1914- 1945.Australian Military History Publications, Loftus NSW, 2007.
  20. See Blakeway, D, Lloyd-Roberts, S.Fields of Thunder: Testing Britain’s Bomb.Unwin Paperpacks, Sydney and London, 1985.
  21. See Horner, D, Australia and the ‘New World Order’: from peacekeeping to peace enforcement: 1988- 1991.The Official History of Australian Peacekeeping, Humanitarian and Post-Cold War Operations.Cambridge University Press, Melbourne, 2011.
  22. See Barton, R, The Weapons Detective: The Inside Story of Australia’s Top Weapons Inspector.Griffin Press, Melbourne, 2006.
  23. See RANSSSS Training Management Package: Standard Combat Survivability dated 22 Apr 2014, (only available on Defence intranet).
  24. See Australian Defence Doctrine Publication Chemical, Biological, Radiological and Nuclear Defence, 2011; Australian Army Land Warfare Procedures – General LWP-G 7-2-5 Conduct of Chemical, Biological, Radiological and Nuclear Training dated 28 April 2014; LWD 3-9-7 Operations in a Chemical, Biological, Radiological and Nuclear Environment dated 13 May 2005; LWP-G 3-9-10 Chemical, Biological, Radiological and Nuclear Defence dated 6 December 2005; Australian Book of Reference 5476 — Volume 1 Royal Australian Navy Shipboard Combat Survivability—Damage Control Policy dated 09 August 2016, (all only available on Defence intranet).
  25. See NATO Standardisation Agreement (STANAG) 2596 Allied Joint Medical Doctrine for Support to Chemical, Biological, Radiological and Nuclear (CBRN) Defensive Operations - AJMedP-7 Edition A; STANAG 2954 Training of Medical Personnel for Chemical, Biological, Radiological, and Nuclear (CBRN) Defence - AMedP-7.3 Edition A, accessed via search for ‘CBRN’], available from http://nso.nato.int/ nso/nsdd/_CommonList.html.
  26. See Defence Instruction (General) Operations 15-1 Australian Defence policy for the development of the capability to conduct operations in a Chemical, Biological, Radiological and Nuclear Environment AL2 dated 29 Jan 2006 (only available on Defence intranet).
  27. Guidance with respect to immunisation against biological warfare agents is in Volume 1 Part 7 Chapter 1 of the Defence Health Manual.Volume 2 Part 7 has 16 chapters on various operational health matters, of which only six pertain to CBRN.
  28. Defence Health Manual Volume 2 Part 5 Health Standards and Assessments - Entry and Transfer (only available on Defence intranet).
  29. For instance, personnel with immune disorders may not be able to be vaccinated against biological agents, while personnel who lack an enzyme called pseudocholinsterase, are more susceptible to nerve agents and are less responsive to nerve agent pre-treatment and post-exposure medications.For another example, personnel with asthma may be at an increased risk of an asthma attack on exposure to chemical agents, yet they cannot use their asthma medication while wearing a respirator.Some personnel may also have an increased risk of heat stress while wearing Mission Oriented Protective Posture (MOPP) suits.
  30. See ‘Australia’s CBRNE Defense’ CBRNe Portal, available from http://www.cbrneportal.com/australias-cbrne-defense.
  31. See ‘US Army Medical Research Institute of Infectious Diseases’, US Army Medical Department, available from http://www.usamriid.army.mil.
  32. See ‘US Army Medical Research Institute of Chemical Defense’, US Army Medical Department , available from https://usamricd.apgea.army.mil/Default.aspx.
  33. See ‘Armed Forces Radiobiology Research Institute’, Uniformed Services University, available from https://www.usuhs.edu/afrri.
  34. ‘Chemical, Biological, Radiological and Nuclear (CBRN) Health Course’, ADF Headquarters Joint Health Command website (only available on Defence intranet).
  35. It is understood a brief (one-day) medical CBRN session was conducted during Exercise BLUESTOKES at HMAS Penguin on 16-20 April 2018, while another was conducted prior to the 2018 Australasian Military Medicine Association Conference.These sessions cannot be considered in any way comparable to the pre-2012 Health Officer CBRN Course (two weeks).
  36. For a description of NATO levels of health care or ‘Roles’, see ‘Chapter 16: Health Support’, NATO Logistics Handbook , available from http://www.nato.int/docu/logi-en/1997/lo-1610.htm.
  37. See ‘1st Close Health Battalion’ Army’s ‘Our People’, available from https://www.army.gov.au/our-people/units/forces-command/17th-combat-service-support-brigade/1st-close-health-battalion.
  38. For a description of Navy’s Maritime Operational Health Unit, see ‘Navy’s Fighting Chance’ Navy Daily, available from http://news.navy.gov.au/en/Jun2014/Fleet/1096/Navy%27s-%27Fighting-Chance%27.htm#.Wbk_EOQh.
  39. Westphalen, ‘Occupational and environmental medicine in the Australian Defence Force’, Australian Defence Force Journal, 2016 , Issue 200, pp.49-58, available from <http://www.defence.gov.au/ADC/ ADFJ/Documents/issue_200/Westphalen_Nov_2016.pdf.
  40. ‘Physician Readiness for Expert Practice (PREP) Training Program Occupational and Environmental Medicine Training Curriculum‘, Royal Australasian College of Physicians, available from https://www.racp.edu.au/docs/default-source/default-document-library/at_occupationalenvironmentalmedicine_ curricula1.pdf?sfvrsn=8.

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